TREATISE ON FRACTURES. 



/ BY 

LEWIS A. STIMSON, B.A., M.D., 

1 7 1 

PROFESSOR OF SURGICAL PATHOLOGY IN THE MEDICAL FACULTY OF THE UNIVERSITY 

OF THE CITY OF NEW YORK ; ATTENDING SURGEON TO THE BELLEYUE AND 

PRESBYTERIAN HOSPITALS, NEW YORK ; MEMBER OF THE 

NEW YORK SURGICAL SOCIETY. 



WITH THREE HUNDRED AND SIXTY ILLUSTRATIONS ON WOOD. 





PHILADELPHIA: 
HENRY C. LEA'S SON & CO 

1883. 



$ ° 



Entered according to Act of Congress, in the year 1882, by 

HENRY C.LEA'S SON & CO., 

in the Office of the Librarian of Congress. All rights reserved. 



COLL IX S , PRINTER. 



CONTENTS. 



CHAPTER I. 

GENERALITIES 

Definitions, statistical tables, influence of age, sex, and season 

CHAPTER II. 

VARIETIES OF FRACTURE 

1. Incomplete fractures : 

Fissures ..... 
True, incomplete, or green-stick 
Depressions .... 

Separation of a splinter or apophysis 

2. Complete fractures . 

a. Subdivided according to the direction of the line of fracture 

b. According to the seat of fracture 

Separation of the epiphysis 

c. Intra- articular fractures 

3. Multiple fractures .... 

Comminuted, impacted, with crushing . 

4. Compound fractures .... 

5. Gunshot fractures .... 



CHAPTER III 

DISPLACEMENTS 

Transverse or lateral ; angular ; rotatory ; overriding ; by penetration or crush- 
ing ; direct longitudinal separation. Active causes 



PAGE 

33 
36 



37 

38 
38 
39 
42 
42 
43 
43 
48 
49 
52 
55 
55 
59 
62 



67 



73 



CHAPTER IV. 








ETIOLOGY . . . .76 


. Predisposing causes . . . . . . .76 


Normal or physiological 






76 


Pathological ..... 






76 


Inherited or acquired liability . 






79 


Osteoporosis .... 






80 


Disease of the nerve centres . . 






82 


Rachitis ..... 




/ 


83 


Syphilis, mercurialism, ' ' rheumatism' ' . 






84 



CONTENTS. 



Cancer . . . 

Cysts ; caries and necrosis 

Immediate or determining causes 

a. External violence 

b. Muscular action 
Intra-uterine fractures, and fractures during delivery 



CHAPTER V. 

SYMPTOMS AND DIAGNOSIS 

Objective signs 

Deformity 

Abnormal mobility 

Crepitation 
Subjective or rational signs 

Loss of function ; pain ; history 



CHAPTER VI 



REPAIR OF FRACTURES 



Clinical description 

Anatomo-pathological processes 

History ; nature of the process ; details 

failure of union 
Details in compound fracture 
Details in the short and flat bones 
Details in articular fractures 
Details in fracture of parallel bones 
Details in separation of an epiphysis 



simple fracture ; splinters 



CHAPTER VII. 

COMPLICATIONS AND REMOTE CONSEQUENCES OF FRACTURE 

Stiffness of the joints . 

Atrophy of the limb 

Obliteration of the large veins ; embolism 

Fat embolism . 

Extravasation of blood . 

Injury of an artery ; traumatic 

Emphysema 

Gangrenous septicaemia 

Gangrene 

Suppuration ; pysemia ; necrosis 

Muscular twitchings and tetanus 

Delirium tremens and nervous delirium 

Exuberant and painful callus 

Paralysis due to injury of a nerve 

Paralysis by inclusion of a nerve in the callus 

Secondary fracture 



CONTENTS. 



CHAPTER VIII. 













PAGE 


TREATMENT OF FRACTURES . . .153 


Reduction ....... 




. 154 


Retention .... 










. 159 


Scultetus bandage 










. 160 


Bivalve cushion . 






.- 




. 161 


Wooden splints . 










162 


Fracture boxes . 










. 163 


Gutters .... 










164 


Posterior and suspended splints . 










164 


Malgaigne's point and hooks 










168 


Moulded splints . 










169 


Plaster of Paris . . 










170 


Inclined plane . 










179 


Continuous extension 










179 


Movements, local and general treatment 










184 


Compound fractures .... 










185 


Suture of the fragments 










187 


Antiseptic (Lister) method 










188 


Modifications 










190 


Treatment of inflammatory processes 










192 


Treatment of articular fractures . 










193 


Treatment of gunshot fractures . 










194 


Amputation 










194 


Aphorisms 










195 



CHAPTER IX. 

PSEUDARTHROSIS AND DELAYED UNION 

Causes, general and local 
Softening and absorption of callus 
Diagnosis 

Treatment, internal remedies . 
Local measures . 



197 

201 

207 
208 
209 
210 



CHAPTER X. 

DEFORMED, FAULTY, OR VICIOU 

Treatment 

Infraction of callus 

Rupture of callus 

Division of callus 

Resection of projecting fragment 

CHAPTER XI 

GENERAL PROGNOSIS 

The patient . . . . 

The fracture ..... 



S UNION 



217 

219 
219 
220 
222 
223 



226 

226 
227 



VI 



CONTENTS. 



CHAPTER XII 













PAGE 


FRACTURES OF THE SKULL . . . 230 


Pathological anatomy ...... 


. 232 


Fractures of the vault . 










. 232 


Fractures of the base 










. 234 


Symptoms and diagnosis — vault 










. 239 


Symptoms and diagnosis — base 










. 241 


Prognosis 










. 246 


Treatment — vault 










. 247 


Treatment — base 










. 252 



CHAPTER XIII. 



Pathology .... 


V H.K,X2jL 


itiJth 




. 255 


Etiology .... 








. 260 


Symptoms and diagnosis 








. 261 


Atlas and axis . 








. 263 


Lower cervical and upper dorsal 








. 264 


Lower dorsal and upper lumbar 








. 267 


Lower lumbar . 








. 269 


Course and terminations 








. 270 


Treatment .... 








. 274 



CHAPTER XIV. 

FRACTURES OF THE BONES OF THE FACE 



1. Fractures of the nose 

2. Malar bone and zygoma 

3. Superior maxilla 

4. Inferior maxilla 

Treatment 



CHAPTER XV. 

FRACTURES OF THE HYOID BONE . 



27? 

277 
280 
282 
284 
289 



295 



CHAPTER XVI. 

FRACTURES OF THE CARTILAGES OF THE LARYNX AND TRACHEA 



297 



CHAPTER XVII. 

FRACTURES OF THE STERNUM 



Etiology 
Treatment 



299 

302 
305 



CONTENTS 



Vll 



CHAPTER XVIII 



FRACTURES OF THE RIBS AND THEIR CARTILAGES 



Pathology and complications 
Etiology . . 

Symptoms 
Treatment . 

Fracture of the costal cartilages 



PAGE 

307 

307 
311 
312 
316 
319 



CHAPTER XIX. 

FRACTURES OF THE CLAVICLE 



323 



Pathology . . - . ■ 


. 




. 324 


Middle third 






. 325 


Outer third 


, 




. 327 


Inner third 






. 328 


Multiple fractures 






. 329 


Complications 


. 




. 330 


Etiology .... 






. 332 


Simultaneous fracture of both clavicles 






. 333 


Symptoms and course . 






. 334 


Treatment 






. 337 



CHAPTER XX. 



FRACTURES OF THE SCAPULA 



Of the body of the scapula 

Of the inferior angle . 

Of the upper angle 

Of the spine of the scapula 

Of the acromion 

Of the coronoid process 

Of the surgical neck 

Of the glenoid cavity . 



345 

346 
348 
349 
349 
350 
351 
353 
354 



CHAPTER XXI. 

FRACTURES OF THE HUMERUS 

1. Fractures of the upper end ...... 

Pathology and course ...... 

a. Fractures of the head ..... 

b. Fractures of the anatomical neck, and through the tuberosities 

c. Fracture of the tuberosities .... 

d. Separation of the epiphysis .... 

e. Fracture of the surgical neck .... 

/. Intra- and extra-capsular fractures, -with dislocation of the upp 
fragment ...... 

Diagnosis ....... 

Treatment . . . 



356 

357 
357 
357 
358 
362 
365 
369 

372 
377 
379 



Vlll 



CONTENTS 



2. Fractures of the shaft of the humerus 

Symptoms, treatment 

3. Fractures of the lower end of the humerus . 

1. Fractures above the condyles 

2. Fractures of the epitrochlea 

3. Fractures of the external epicondyle 

4. Fractures of the internal condyle 

5. Fractures of the external condyle 

6. Intercondyloid fractures 

7. Separation of the epiphysis . 

8 Fracture of the articular process 

9. Simultaneous fracture of all three bones 

Diagnosis 

Treatment .... 



PAGE 

384 
386 
389 
390 
391 
395 
396 
403 
405 
411 
413 
413 
414 
415 



CHAPTER XXII. 

FRACTURES OF THE BONES OF THE FOREARM 

A. Fractures in the vicinity of the elbow-joint 

1. Of the olecranon . . . 

Symptoms .... 
Repair .... 

Treatment .... 

2. Of the coronoid process of the ulna . 

3. Of the head and neck of the radius . 

B. Fractures of the shaft 

1 . Of both bones 

Treatment . 

2. Of the shaft of the ulna 

3. Of the shaft of the radius 

C . Fractures in the vicinity of the wrist 

1. Fracture of the radius. Colles's fracture 

Causes .... 

Symptoms and diagnosis 

Course and prognosis 

Treatment .... 

2. Fractures at the wrist other than Colles's 



418 

418 
418 
420 
422 
425 
427 
431 
435 
435 
439 
442 
444 
446 
446 
455 
457 
459 
460 
464 



CHAPTER XXIII. 

FRACTURES OF THE CARPUS AND HAND 



1 . Fractures of the carpus 

2. Fractures of the metacarpal bones . 

3. Fractures of the phalanges . 



466 

466 
467 
469 



CONTENTS 



IX 



CHAPTER XXIV 



FRACTURES OF THE PELVIS 



1. Fractures of the ring of the pelvis . 

Separation of the symphysis pubis 

Separation in front and behind 

Separation of the sacro-iliac synchondrosis 

Separation of all three joints 

Fracture of the pubic portion 

Fracture of the lateral portion 

Course and prognosis 

Diagnosis 

Treatment 

2. Transverse fracture of the sacrum 

3. Fractures of the coccyx 

4. Fractures of the ilium 

5. Fractures of the ischium 

6. Fractures of the pubis 

7. Fractures of the rim of the acetabulum 



PAGE 

472 

472 
473 
475 

475 
475 
476 
477 
480 
480 
481 
481 
482 
483 
484 
485 
486 



CHAPTER XXV. 



FRACTURES OF THE FEMUR 



1. Fractures at the upper end . 

A. Fractures of the neck of the femur . 

Causes 

Anatomical varieties 

a. Fractures of the small part of the neck 

Separation of the epiphysis 

Symptoms 

Repair 

b. Fractures at the base of the neck 

Repair 
Symptoms .... 
Diagnosis .... 
Prognosis . 
Treatment .... 

B. Fracture through great trochanter and neck 

C. Fracture of the great trochanter 

2. Fractures of the shaft of the femur 

Prognosis .... 

Treatment .... 

In children .... 

3. Fractures at the lower end of the femur 

A. Supra-condyloid fracture and separation of epiphysi 

B. Inter-condyloid fracture 

C. Fracture of either condyle . 



488 

4S8 
489 
491 
492 
494 
496 
496 
498 
504 
508 
508 
513 
515 
517 
520 
522 
524 
528 
529 
536 
538 
538 
540 
543 



CONTENTS. 



CHAPTER XXVI 





PAGE 


FRACTURES OF THE PATELLA . 


. 546 


Cause ... . . 


. 546 


Pathology . . . . 


. 547 


Symptoms ....... 


. 550 


Course and terminations ...... 


.550 


Treatment 


. 556 


Of compound and ununited .... 


. 561 



CHAPTER XXVII. 



FRACTURES OF THE BONES OF THE LEO 



A. Fractures of the upper end of both bones, or of the tibia alone 

Treatment . . 

B. Fractures of the shaft 

Treatment 

C. Fractures at the lower end of the leg 

1. Fractures by inversion of the foot 

2. Fractures by eversion of the foot 

D. Fractures of the fibula 

Upper end 

Shaft .... 



564 

564 
567 
567 
570 
576 
578 
581 
586 
586 
587 



CFIAPTER XXVIII. 

FRACTURES OF THE BONES OF THE FOOT 



A. Fractures of the astragalus 

B. Fractures of the calcaneum 

C. Fractures of the metatarsal bones 

D. Fractures of the phalanges . 



588 

588 
589 
592 
593 



LIST OF ILLUSTRATIONS, 



FIG. 

1. Fissured fracture . 

2. Fissure of the humerus 

3. Green-stick fracture of the radius . 

4. 5. Partial fracture of the fibula . 
6, 7. Transverse fracture of the femur 

8. Toothed fracture of the femur 

9. Toothed fracture of the tibia 

10. Y-shaped fracture 

11. Oblique fracture of the humerus . 

12. Oblique fracture of the clavicle . 

13. Oblique fracture of the femur 

14. Longitudinal fracture of the tibia 

1 5. Sepai-ation of the lower epiphysis of the femur 

16. Intra- articular fracture of the head of the tibia 

17. Intra- articular fracture of the humerus 

18. Inter-condyloid fracture of the humerus . 

19. Multiple fracture of the bones of the leg . 

20. Multiple fracture of the fibula 

21. 22. Comminuted fracture of the femur 

23. Comminuted fracture of the radius 

24. Impacted fracture of the neck of the femur 

25. Partial gunshot fracture . 

26. Perforating gunshot fracture 

27. Gunshot fracture .... 

28. Comminuted gunshot fracture 

29. Gunshot fracture with impacted ball 
30,31. Lateral and angular displacement 
32, 33. Angular displacement 

34, 35. Clavicle, union with great displacement 

36. Rotatory displacement 

3 7. Fracture of leg, with overriding . 

38. Fracture of femur, with splitting of the condyles 

39. Fracture of calcaneum, with crushing 

40. Impaction and splitting of the head of the tibia 

41. Impaction of the neck of the femur 

42. Impaction of the neck of the humerus 

43. Angular displacement and impaction of radius 

44. Longitudinal separation, fibula 

45. Patella, bony union 

46. Patella, long fibrous union 



PAGE 

38 
39 
40 
40 
43 
44 
45 
45 
45 
46 
47 
47 
49 
53 
54 
54 
56 
56 
58 
58 
58 
63 
63 
63 
64 
64 
68 
68 
69 
69 
70 
70 
70 
71 
71 
71 
71 
71 
72 
72 



Xll 



LIST OF ILLUSTRATIONS. 



FIG. 

47. Irregular displacement of neck of femur 

48. Irregular disj)lacement of clavicle 

49. Penetration of the astragalus between the tibia and fibula 

50. Comminuted fracture of neck of femur . 

51. 52. Diagram of the bones of the thigh and leg 

53. Clavicle, osteomalacia 

54. United fracture of rachitic femur 

55. Cancer of the femur, fracture 

56. Fracture of carious femur 

57. Diagram concerning measurement of limb 

58. Thermograph in simple fracture 

59. Thermograph in compound fracture 

60. Periosteal bridge 

61. Callus on sixth day, pigeon 

62. Callus on seventh day, rabbit . . , 

63. Callus on fifteenth day . 

64. Callus and adjoining rarefied bone 

65. Large splinter reversed and united 

66. Humerus, failure of union 
6 7, 68. Bony union of patella 

69. Absorption of neck of femur after fracture 

70. Exuberant callus, lower end of humerus 

71. Bony ankylosis of foot and ankle 

72. Forearm, angular displacement and union 

73. Forearm, lateral joint 

74. Fibrous union, olecranon 

75. 76. Necrosis after fracture 

77. Inclusion of a nerve in a callus . 

78, 79. Scultetus bandage 
80, 81. Bivalve cushion 

82. Gooch's flexible wooden splint . 

83. Petit' s fracture box 

84. Scheuer's box splint 

85. Baudens's fracture box . 

86. 87. Wire gutters for arm and leg 

88. Mayor's suspension dressing 

89. Mclntyre's splint and Salter's swing 

90. Suspended fracture box for compound fracture 

91. N. R. Smith's anterior splint 

92. Hodgen's splint . 

93. 94. Hodgen's cradle 
95, 96. Malgaigne's point 

97. Anger's apparatus for alternate pressure 

98, 99. Malgaigne's hooks . 

100. Posterior plaster splint . 

101, 102. Anterior and posterior plaster splint 

103. Bavarian splint . 

104, 105. Plaster of Paris dressing 
106. Fenestrated plaster dressing 



LIST OF ILLUSTRATIONS. 



Xlll 



FIG. 

107. Interrupted plaster dressing . ' . 

108. Esmarch's double inclined plane 

109. 110, 111. Adhesive plaster to make extension 

112. Volkmann's sliding foot-rest 

113. Hamilton's long side splint 

114. Continuous extension by India rubber . 

115. Cripp's splint .... 

116. Campbell de Morgan's splint 

117. Lister dressing, compound fracture 

118. 119. H. H. Smith's splints for ununited fracture 

120. Volkmann's operation for pseudarthrosis 

121. Vicious union, femur 

122. 123. Vicious union, fibula 

124. Vicious union, tibia . 

125, 126. Depressed fracture of skull 

127. Fracture of skull from within 

128. Fracture of the clinoid process . 

129. Fracture of the skull by the condyle of the jaw 

130. Fracture of the base 

131. Fracture of the base, by a blow upon the nose 

132. Fracture parallel to the axis of the temporal bone 

133. Repair after trephining . 

134. Transverse fracture of a vertebra 

135. Compression of the cord by displaced vertebra 

136. Compresion of a vertebra 

137. 138. Fracture and compression of vertebrae 

139. Laceration of spinal cord 

140. Fracture of the axis 

141. Ankylosis by fusion of the vertebrae 

142. Splint for fracture of the upper jaw 

143. Fracture of the lower jaw 

144. 145, 146, 147, 148. Fracture of the lower jaw, dressings 
149, 150. Fracture of the lower jaw, pasteboard splint 

151. Fracture of the lower jaw, metal splint . 

152, 153. Fracture of the lower jaw, Kingsley's splint 

154. Hyoid bone, united fracture 

155. Diastasis of the sternum 

156. Longitudinal fracture of the sternum 

157. Transverse fracture of the sternum 

158. Rib, union after fracture 

159. Rib, exuberant callus 

160. Adhesive plaster dressing for fracture of ribs 

161. 162. Costal cartilage, repair after fracture 

163. Clavicle, oblique fracture 

164, 165. Clavicle, fracture with great displacement 
166, 167. Clavicle, fracture in outer third 

168. Clavicle, fracture in inner third . 

169. Clavicle, union with great displacement . 

170. Clavicle, mechanism of displacement 

171. 172. Clavicle, Mayor's and Velpeau's dressings 



PAGE 

176 
179 
181 
182 
182 
183 
183 
183 
190 
210 
216 
217 
219 
224 
233 
233 
235 
236 
236 
237 
238 
247 
256 
256 
256 
257 
259 
264 
270 
284 
285 
l, 290 
291 
292 
192, 293 
296 
299 
299 
301 
313 
314 
317 
322 
325 
326 
328 
329 
336 
337 
340 



XIV 



LIST OF ILLUSTRATIONS 



FIG. 

173, 174. Clavicle, Sayre's dressing . 

175, 176. Clavicle, Fox's dressing 

177. Clavicle, Reeamier's dressing 

178, 179. Clavicle, Moore's dressing . 

180. Scapula, transverse fracture 

181. Scapula, mnltiple (longitudinal) fracture 

182. Scapula, fracture of posterior angle 

183. Scapula, fracture of coracoid process 

184. Scapula, fracture of the neck 

185. Humerus, fracture of the head . 

186. Humerus, fracture of the anatomical neck 

187. Humerus, fracture of the neck and tuberosities : 

188. Humerus, fracture through the tuberosities 

189. 190. Humerus, impacted fractures at the head . 

191. Humerus, fracture through tuberosities, reversal of head 

192. Humerus, fracture of the greater tuberosity 

193. Humerus, separation of the upper epiphysis 

194. 195, 196. Humerus, upper epiphyseal line 

197. Humerus, separation of upper epiphysis (clinical) 

198. Humerus, separation of upper epiphysis (union) 

199. Humerus, fracture of surgical neck 

200. Humerus, fracture of neck, impaction 

201. Humerus, fracture of neck, displacement 

202. Humerus, fracture of neck, dislocation . 

203. Humerus, moulded splint 

204. Humerus, angular internal splint 

205. Humerus, Middledorpf's triangle 

206. Humerus, fissure .... 

207. 208. Stromeyer's axillary cushion 
209, 210, 211. Humerus, supra-condyloid fracture 

212. Humerus, fracture of epitrochlea 

213. Humerus, fracture of external epicondyle 

214. The elbow-joint ..... 

215. The outward deflection of the forearm . 

216. Relations of the bones of the arm and forearm . 

217. Deformity after fracture at the elbow 

218. Humerus, fracture of the internal condyle 
219-224. Humerus, intercondyloid fracture . 

225. Humerus, intercondyloid fracture, displacement forward 

226, 227. Fracture at elbow, interrupted splints 

228. Humerus, lower epiphyseal line . 

229. Fracture at the elbow, anterior splint 

230. The olecranon, divided vertically 

231. The olecranon, bony union after fracture 

232. The olecranon, fibrous uuion 

233. 234. The olecranon, ununited fracture . 

235. Coronoid process of ulna, union after fracture 

236. Coronoid process of ulna and head of radius, fracture 

237. Neck of the radius, union after fracture 

238. Fracture of the forearm, angular displacement, union 



PAGE 

341 
342 
343 
344 
345 
346 
349 
352 
353 
357 
358 
359 
359 
360 
361 
365 
367 
367 
368 
369 
369 
370 
370 
374 
380 
380 
381 
384 

387, 388 

390, 391 
. 392 
396 
397 
397 
. 398 
399 
401 

405, 406 
410 
411 
412 
416 
418 
422 
423 

424, 425 
429 
429 
433 
439 



LIST OF ILLUSTRATIONS. 



XV 



FIG. PAGE 

239. Fracture of the forearm, formation of lateral joint . . . 439 

240. Fracture of the forearm, Scott's splint ..... 442 

241. Fracture of the shaft of the radius ..... 445 

242. Fracture of radius and ulna ...... 445 

243. 244, 245. Fracture of the lower end of the radius . * . 448 

246. Comminuted fracture of radius, articular surface . . . 449 

247. Recent fracture of the lower end of the radius . . . .449 

248. Impacted fracture of the lower end of the radius . . . 450 
249,250. Fracture of lower end of radius, union .... 450 

251. Fissured fracture of lower end of radius . .... 454 

252. Section through the hand and wrist . . . . . 456 

253. Deformity in Colles's fracture ...... 458 

254. Colles's fracture, union with displacement .... 458 
255,256. Colles's fracture, splints . . . . . 462 

257. Colles's fracture, Levis' s splint . . . . . .462 

258. Colles's fracture, Gordon's splint ..... 463 

259. Gutta percha splint for finger ...... 470 

260. Double vertical fracture of pelvis, united . . . .477 

261. Double vertical fracture of pelvis . . . ."'■•. 478 

262. Perforation of acetabulum by the femur .... 480 

263. Neck of the femur ....... 490 

264. 265. Neck of the femur, impacted intracapsular fracture . 494, 497 
266, 267. Neck of the femur, pure intracapsular fracture, bony union . 500 

268. Neck of the femur, impacted intracapsular fracture . . . 501 

269. Neck of the femur, intracapsular fracture, fibrous union . ■ 501 

270. Neck of the femur, fracture at the base, section . . . . 505 

271. Neck of the femur, impacted fracture without splintering . . 506 

272. Neck of the femur, repair after fracture .... 506 
273-276. Neck of the femur, comminuted fracture . . . 506,507 

277. Neck of the femur, exuberant callus . . . . .507 

278. Bryant's ilio-femoral triangle . . . . . .511 

279. Relaxation of the fascia lata . . . . . . 511 

280. The Y-ligament, in ununited fracture ..... 516 

281. The obturator tendon, in ununited fracture . . . .517 

282. Hennequin's splint for fracture of the neck of the femur . .519 

283. Fracture through the great trochanter ..... 521 

284. Fracture or diastasis of the great trochanter .... 522 

285. 286, 287. Fractures of the shaft of the femur . . . .525 
288, 289. Fractures of upper third of femur, union with great displacement . 526 

290. Fracture of neck and shaft of femur, reversal of a splinter . . 527 

291. Adhesive plaster applied for Ruck's extension .... 529 

292. Volkmann's sliding foot-rest ...... 530 

293. Hamilton's long side splint ...... 531 

294. 295, 296. Long side splints and elastic extension . . . 532 

297. Hennequin's apparatus for fracture of the femur . . . 533 

298. N. R. Smith's anterior splint . . . . . . 534 

299. Hodgen's splint ........ 534 

300. Plaster of Paris dressing, fracture of thigh .... 535 

301. Plaster of Paris dressing, application • . . . . 536 

302. Vertical extension in fracture of femur in children . . . 536 



XVI 



LIST OF ILLUSTRATIONS. 



FIG. 

303. Hamilton's splint for fracture of femur in children 

304. Separation of the lower epiphysis of the femur 

305. 306, 307. Interc'ondyloid fractures of the femur 

308. Plaster splints, suspension 

309. Fracture of the internal condyle of the femur 

310. Patella, incomplete fracture 

311. Patella, vertical fracture 

312. Patella, oblique fracture 

313. Patella, comminuied fracture, bony union 

314. Patella, fibrous union with wide separation 

315. Patella, bony union 

316. Patella, fibrous union 

317. 318, 319. Patella, bony union 

320. Patella, multiple fracture 

321. Patella, extreme separation, clinical 

322. Patella, Agnew's splint . 

323. Patella, Agnew's splint applied . 

324. Patella, Hamilton's dressing 

325. Patella, Laugier's dressing 

326. Patella, treatment by elastic traction 

327. Patella, Malgaigne's hooks 

328. Patella, Levis' s modification 

329. Patella, Trelat's dressing 

330. Patella, LeFort's dressing 

331. Impacted fracture at the upper end of the tibia 

332. Arrest of growth after injury to upper epiphysis of tibia 

333. Y-shaped fracture of the tibia 

334. 335. Fracture boxes 

336. Bonnet's gutter for the leg 

337. Leg encased in plaster of Paris . 

338. Bavarian splint .... 

339. Posterior plaster splint . 

340. 341. Dr. Neill's dressing for fracture of leg 

342. Method of continuous extension in fracture of le 

343. Liston's double inclined plane . 

344, Mclntyre's splint and Salter's cradle 

345, 346. Malgaigne's point . 

347. Anger's apparatus for alternate pressure 

348. Compound fracture, Lister dressing and plaster splint 

349. Anterior and posterior splint 

350. Interrupted plaster dressing 

351. Comminuted fracture of lower portion of leg 

352. Vertical section through the malleoli 

353. Fracture of the internal malleolus 

354. Supra-malleolar fracture 

355. Diagram of Pott's fracture 

356. Displacement in Pott's fracture . 

357. 358. Vicious union after fracture of the fibula 

359. Dupuytren's splint . . . 

360. Fracture of the calcaneum 



PRACTICAL TREATISE ON FRACTURES. 



CHAPTER I. 

By Fracture, in the surgical sense of the term, is meant the breaking 
of a bone or cartilage. 

The liability to fracture of the different bones of the body varies 
greatly in consequence of their differences in size, shape, and degree of 
exposure to external violence or extreme muscular action. Hospital 
records covering periods varying in length from five to eighty-seven 
years, have been tabulated by different writers, with the object of deter- 
mining accurately the relative degree of this liability, and the data thus 
obtained have served as the basis of most of the opinions current upon 
this point. 

It is evident that such statistics cannot present accurately the desired 
facts, for the reason that many of the cases of simpler, less important 
fractures do not need or seek treatment in a hospital. Gurlt, who pub- 
lished in 1862 a most valuable work upon fractures, unfortunately left in- 
complete, collected six sets of hospital statistics published by other au- 
thors, and three sets, one of them being his own, of combined hospital 
and dispensary practice. The differences are notable, and if Malgaigne's 
list be taken as the type of one and Gurlt's as the type of the other, 
it appears that the principal difference is in the relative number of the frac- 
tures of the upper and of the lower extremities, Malgaigne giving in a 
total of 2347 cases 921 fractures of the upper extremity, including the 
clavicle, and 1024 of the lower extremity, while Gurlt gives in a total 
of 1631 cases 805 fractures of the upper extremity and only 569 of the 
lower. 

The following table is the one above referred to, of hospital and dis- 
pensary patients, and is taken from Gurlt. 1 

1 Gurlt, Handlruch. der Lehre von den Knoclienbriichen, 1862. 



34 



FRACTURES. 



Statistics of Fractures Treated in Hospital and Dispensary. 





Lousdale, 










London. 


Blasius, 


Gurlt, 






Middlesex 


Halle, 


Berlin. 




Bones. 


Hospital, 
1831-37. 


1831-56. 


1851-56. 


Total. 


Cranium ... 


481 

13 ' 94 
1 f head. 


17] 
8 1 42 
6 f head. 

HJ 


r-51 

11 1 89 

•H j head. 

13J 


1201 


Nose . 


32 i 225 
17 f head. 


Sup. max. and zygoma 


Inf. max 


32J 


56J 


Vertebral column 


-L ' 392 
3 °l 1" trunk. 

ISJ 


4] 


H 


211 


Pelvis 

Ribs 

Sternum , 


3? L 54 

1 j trunk - 


16 1 158 
104 f trunk. 

25 J 


30 rnJ 

49 S L 604 
4b ° f trunk. 


Scapula . . . . 


4J 


47J 


Clavicle . 


273 "1 


113 




123 




509 




Neck of humerus 


13) 




15 1 




57 ) 




861 v 
219 UlO 

106) 




Shalt 


59 > 118 




5.5 S 76 




75 } 216 






Condyles .... 


16 J 


893 


6$ 


419 


S4) 


S05 


2117 


Forearm .... 


931 

197 Urr 
66 f 3S6 
30 J 


upper 


691 


^ upper 


1371 


upper 

'extrem- 

ity. 


299 1 


upper 
^extrem- 
ity. 


Radius 

Ulua 


"extrem- 
ity. 


26 \lQo 


extrem- 
ity. 


1\>S 1 

28 h 309 


Jg [-860 

59 J 


Olecranon .... 




13 j 




16J 






Metacarpal .... 


50 




20 




34 




104 




Phalanges .... 


66 J 




45 J 




123 J 




234 j 




Neck of femur . . ) 
Shaft and condyles . $ 


181 fern.] 


Sj ^ 




156 j 232 ' 




510 




Patella .... 

Leg 

Tibia 

Fibula . . . . . 


i 3S 5<>2 
\ l l' (289 1 lower 
51 S le ^ | extrem " 


20 

30 ( 139 
15 ) 


263 

lower 

extrem- 


2-? 

1731 
g ^83 


569 

lower 

^extrem- 


80 
4641 

107 L'7il 

108 f ' il 

32 1 


1354 
lower 

extrem- 


Malleoli .... 


.. ' ity - 




ity. 


32j 


ity. 


ity. 


Tarsus and metatarsus 


.3 


*7 




23 




33 




Phalanges .... 


11 J 


J 




9 J 


20 j 




Unknown . 






10 


10 












1901 


778 


1631 


4310 



Shortly afterwards Gurlt 1 published the following table made up from 
twenty annual reports of the London Hospital. Its numbers are much 
larger than those of any other collection, but the details are somewhat 
scanty. So far as it goes it confirms Gurlt as against Malgaigne. 



Laugenbeck's Archiv, 1862, vol. iii. p. 394. 



FRACTURES. 



35 



Fractures in London Hospital 1842-1862. 



Ia Hospital. 


" Out-patients." 


Total. 


Head, S 296 skull 

630 I 334 bones of face .... 

( 74 spine 

m -, 70 pelvis 

Jrunk, i r>- nA ., 

3032 2 ™ribs 

20 sternum .... 
[ 78 scapula . . . . . 

yr , f 285 clavicle ..... 

i .. i 546 humerus .... 
extremitv, < OOA f 

ifidA i 3b4 forearm 

10 " 4 1, 419 hand 

T f 1373 femur ..... 

J j0wei ; 302 patella 

extremitv, < 9Q9 i, f 

5440 ^ 333/ le § 

D44U t 428 foot 


192 I 204 

1 1 
3 i 

1044 j> 1,202 

2 I 
152 j 

3182 1 

}!?? [10,285 
411o f 

1883 J 

811 

8 2 [ 239 

71 j 


mi ^ 

75 1 

73 | 

3834 }■ 4,234 

22 j 

230 J 

3417 1 

4499 | ^ 
2302 J 

1454 1 

34 19 \ 5 ; 6 ' 9 
499 J 


Totals 10,686 


11,930 


22,616 



He followed this in 1880 1 with the following table made up from the 
records of the same hospital from 1842 to 1877 
very close. 



The agreement is 



Fractures Treated in the London Hospital 1842-1877. 





Hospital. 


"Out-patients." 


Total. 


Per cent. 




Skull .... 
Face .... 


730 
732 


27 
513 


757 
1.245 


1.457 1 
2.397 j 


Head 2002 
3.854 per ct. 


Spine .... 

Pelvis .... 

Coccyx 

Ribs .... 

Sternum 

Scapula 


169 

139 

5 

4,7S4 

45 

135 


3 

3 

10 

3,477 

290 


172 

»? 

15 

8,261 

52 

425 


0.331 1 
0.273 | 
0.028 : 
15.905 f 
0.1 | 
0.818 J 


Trunk 

9067 

17.457 per ct. 


Clavicle 

Arm .... 

Forearm 

Hand .... 


382 

1,064 

709 

856 


7,458 
3,020 
8,731 
4,899 


7.840 
4,084 
9,440 
5,755 


15.094 1 

7.S63 ' 

18.175 f 

13.080 J 


Upper 

extremity 

27,119 

52.214 per ct. 


Thigh .... 

Patella 

Leg .... 

Foot .... 


3,072 

649 

8.067 

965 


171 

15 

256 

555 


3,243 

664 
8.323 
1,520 


6.243 1 

1.278 ! 

16.024 f 

2.926 J 


Lower 

extremity 

13,750 

26.473 per ct. 




22,503 


29,435 


51,938 



The relative frequency of fractures as compared with other surgical 
injuries is shown by the following facts. During the same period there 



1 Langenbeck's Archiv, 1880, p. 466. 



36 FRACTURES. 

were treated in the same hospital, 5212 dislocations, 98,373 wounds, 
23,180 contusions, 39,917 sprains, 20,396 scalds and burns, 3715 dog- 
bites, and 975 suicidal attempts. 

Sex. — All statistics show that fractures are more numerous in men 
than in women, in the proportion of about three to one, taking all cases, 
but this proportion varies greatly at different ages. In infancy the dif- 
ference is slight ; in middle life fractures are ten times as frequent in 
men as in women ; between the ages of fifty and seventy years the dif- 
ference again becomes slight ; and after the age of seventy fractures are 
much more common in women than in men, a reversal of conditions due 
to a disproportionate increase in the number of fractures of the neck of 
the femur. 

Age. — Tabulation of the fractures contained in Gurlt's table, with 
reference to the ages of the patients, shows in the first decade 265 ; in the 
second, 193 ; in the third, 274 ; in the fourth, 224 ; in the fifth, 154 ; 
in the sixth, 155 ; in the seventh, 72 ; in the eighth, 38 ; and in the 
ninth, 8. These figures are far from expressing the relative frequency 
of fracture at the different ages, unless they are considered in connec- 
tion with others showing the relative number of people living at the 
different periods. Malgaigne did this with accuracy, and, comparing 
successive periods of five years, found that the period between the ages 
of fifty -five and sixty furnished the largest number of fractures in pro- 
portion to population. It must be borne in mind, however, that his 
statistics included only hospital cases. Gurlt's corresponding estimate 
gives the highest proportion of fractures to the period above sixty years 
of age. He further attributes the frequency of fracture in early child- 
hood to rachitis ; an opinion which does not appear to be shared by 
other writers. 

Season. — Ambroise Pare declared that the bones were more fragile 
when the temperature of the air was below the freezing-point than at 
other times, and this opinion has been generally held since his time to 
the extent, at least, of believing that fractures are more common in winter 
than in summer. Malgaigne overthrew the claim by statistics, except as 
regards women, who show an increase of nearly one-third in the winter. 
Gurlt's statistics show that the difference between the two seasons is 
very slight, and do not confirm Malgaigne's statement concerning the 
greater frequency in women in winter. 



VARIETIES OF FRACTURE. 37 



CHAPTER II. 

VARIETIES OF FRACTURE. 

The varieties of fracture are numerous and are constituted by differ- 
ences in the extent of the injury to the bone, or to the surrounding soft 
parts, in the seat and direction of the fracture, in the relation of the 
fragments to each other, and in the number of bones involved. These 
varieties may be grouped in five divisions, marked by important clinical 
differences and containing many subdivisions, as follows : — 

1. Incomplete fractures. 

(a) Fissure. 

(6) True, incomplete, "green-stick" fracture ; bent bone. 

(c) Depressed. 

(c?) Separation of a splinter or of an apophysis. 

2. Complete fractures, subdivided according to — 

(a) Direction of the line of fracture into transverse, oblique, 
longitudinal, toothed or dentate, and V-shaped. 

(5) Seat of the fracture, into fracture of the shaft of the bone, 
of the neck of the bone, of the epiphysis, intercondyloid, 
separation of epiphysis ; and, 

(c) If communicating with a joint, intra-articular. 

3. Multiple fractures, comprising fractures of two or more different 

bones, two or more fractures of the same bone at different points, 
comminuted or splintered fractures, impacted fractures, and frac- 
tures with crushing. 

4. Compound fractures. 

5. Gunshot fractures. 

The term simple fracture, when used in its strictly technical sense, 
means that the bone is broken at only one point ; but it is also in com- 
mon use, in contradistinction to the term compound, to indicate that there 
is no associated wound of the soft parts which establishes communication 
between the fracture and the exterior. Some writers make also a class 
of complicated fractures to include cases in which, in addition to the 
fracture itself, there exists some other important injury, such as the rup- 
ture of a nerve or of an artery, or the laceration of a joint ; and there 
are still other terms in use to indicate peculiarities which do not lend 
themselves easily to the above classification. Such are : Spontaneous 
fracture, a fracture produced by the minimum of violence ; pathological 
fracture, a fracture due to previous partial destruction of the bone by a 
tumor ; recent, and old, or ununited, fractures. This classification is 
not claimed to be absolutely correct in the scientific or even in an ana- 



88 



VARIETIES OF FRACTURE. 



tomical sense, but it is a serviceable one, and one recognized by all 
writers, although some of the subdivisions are differently placed. 



1. Incomplete Fractures. 

Under this head will be considered fractures of long bones, in which 
the continuity of the bone has not been completely lost, and fractures of 
flat bones in which the line of fracture does not extend from one side to 
the other. 

(a) Fissures. — This variety of incomplete fracture is characterized by 
the existence of a split or crack of variable length and depth in the bone, 
one which does not entirely circumscribe a fragment and separate it 
from the rest of the bone. It is of common occurrence in the bones of 
the cranium, not very infrequent in the ribs, and very rare in the long 
bones, except when associated with other varieties. In the latter case, 
and when the sides of the fissure are somewhat separated from each 
other, it is sometimes described as a longitudinal fracture. When sev- 
eral frssures radiate from a central point at which there is usually con- 
siderable splintering, depression, or crushing, the injury is called a 
"starred" or " stellate" fracture. 

The existence of this form of fracture in the flat bones, and especially 
in those of the cranium, has been admitted since the time of Hippocrates. 
Every pathological museum contains examples of it. In the short or 
spongy bones it is so rare as to be almost unknown, and it is only of late 
years that its occurrence in the long bones has been positively demon- 
strated. This rarity may be due in part to the dif- 
Fig. l. ficulty of diagnosis when the bone is not exposed 

to view. A simple fissure of the skull, for example, 
often passes unrecognized by the finger or the eye 
until after the peritoneum covering it has been re 
moved. 

Fissures occur frequently in the long bones in 
connection with complete fracture, are sometimes 
very long, and may extend into a neighboring joint. 
They always involve the entire thickness of the com- 
pact substance. They are commonly found in con- 
nection with gunshot fractures, and with those pro- 
duced by great violence, as in falls from a height, 
and they constitute an important complication in the 
Y-shaped fractures of the tibia. 

The examples of simple fissure of long bones un- 
connected with complete fracture are very rare, but 
are demonstrative of the fact. Fig. 2, copied by 
Fissured fracture. Gurlt from Froriep, represents a linear fracture or 
fissure extending from the greater tuberosity of the 
humerus down to the lower fourth of the shaft, produced in a boy by a 
fall upon the elbow. Four other cases in which the nature of the injury 
was established by examination of the specimen immediately after the 
occurrence presented similar, well-defined fissures ; one of the humerus, 
two of the radius, and one of the tibia. These cases are amply sufli- 




INCOMPLETE FRACTURES. 



39 



Fig-. 2. 



cient to prove the possibility of this form of fracture without the aid of 
Malgaigne's clinical proofs, which are not all entirely 
beyond suspicion as to the correctness of the diagnosis. 

The mechanism by which the fissure is produced in 
long bones, in those cases in which it exists alone, is not 
definitely known. In two of the cases mentioned above, 
the immediate, exciting cause was extreme violence ex- 
erted upon one end of the fractured bone in a direction 
parallel to its long axis ; this is suggestive of a possible 



in " green-stick' 1 



begins at one 



fracture, with 
end and 



bending of the bone as 

this difference, that the fracture 

not in the middle. 

This mechanism is shown very plainly in a case re- 
ported by Debrou in 1843, and quoted by Gurlt as a case 
of infraction or bent fracture. The patient, a man sixty- 
two years old, fell while walking, and injured his thigh. 
Ei^sipelas set in and caused his death. At the autopsy 
a fissure was found under the unbroken periosteum ex- 
tending six inches downward from the trochanter minor, 
and this fissure could be made to widen by pressure upon 
the ends of the bone. 

The diagnosis cannot be made with certainty, except 
when the bone is exposed to direct examination through 
a wound of the overlying soft parts ; but it can be in- 
ferred with much probability in some forms of fracture of 
the limbs with which it is usually associated, such as perforating gunshot 
wounds and Y-shaped fractures of the tibia, and from the symptoms in 
fracture of the skull. 

Except in the bones of the cranium, or when it extends into a joint, 
the importance of a fissure is probably slight, and is dominated by that 
of the associated lesions. It heals, as do other fractures, by bony or 
fibrous union. In some cases the injury has been promptly followed by 
suppuration within the bone and a train of consequences ending in 
death or amputation; in others, suppuration has been discovered two or 
three months after the injury, under the periosteum, or within the medul- 
lary canal, under circumstances which make it probable that it was due 
rather to direct contusion of the bone than to the fissure itself. The 
extension of a fissure into a joint is a serious complication. 



Fissure of the 
humerus. (Gurlt.) 



(])) True incomplete, " green- stick" fracture; bent bone. 

Syn. Fractura incompleta, Infractio. Infraction, Curvature without 
fracture. 

This variety is characterized by a fracture involving only a portion of 
the thickness of a long bone, and combined with a bending of the bone 
at the seat of the fracture. It is male by some authors to include also 
depressions or partial fractures of flat bones, a variety which will be 
considered in the next section. It includes also the rare cases of simple 
curvature without recognizable fracture. 

It has been objected that a rigid material like bone cannot undergo a 
sudden, violent, and permanent change of form without fracture of all 



40 



VARIETIES OF FRACTURE. 



its fibres at the point where the change takes place. The objection is 
a purely verbal one. It may be, and probably is, true that no perma- 
nent change of form can occur without some shifting of the relations 
between the minute elements, but so long as this, shifting cannot be recog- 
nized by the means at our disposal, so long as the continuity of the bone 
is actually preserved, it cannot be said that a fracture exists. 

As a matter of fact, ascertained by post-mortem examination and by 
experiments upon animals and upon cadavers, there exist all degrees of 
change between simple curvature without recognizable fracture at any 
point and complete fracture. Anatomically a distinction may be made 
between simple curvature and partial fracture, but clinically the distinc- 
tion does not exist. Simple curvature has been produced experimentally 
in young animals, and occasionally, but very rarely, upon the bodies of 
young children in the fibula when the tibia has been broken. A clinical 
and post-mortem demonstration of its occurrence has never been made, 
if we except a single specimen belonging to Prof. Uhde, of Brunswick, 
the ulna of an adult much bent by a machinery accident, and showing 
no trace of fracture. This specimen is mentioned by Gurlt, but without 
details. After most attempts to produce this variety of fracture expe- 



Fiff. 3. 





Partial or green-stick fracture of 
the radius. 



Partial fracture of the 
fibula, a, the head ; 
b, the malleolus. 



Partial fracture 
of the fibula. 



rimentally, careful examination shows a number of minute fractures at 
the point of greatest curvature. Ordinarily, partial fracture appears 
as a short transverse fracture, continuous with one or more longitudinal 
ones of variable length; sometimes there is no transverse line of frac- 



INCOMPLETE FEACTUKES. 11 

ture, but only oblique ones running from the point of greatest curvature 
upwards or downwards along the shaft of the bone. The appearance 
can be very closely imitated by over-bending a green or tough stick, a 
fact that has given this form of fracture the name by which it is very 
commonly known. The periosteum may or may not be broken at the 
point or along the line of fracture. 

A few instances are recorded of supposed incomplete fracture of the 
neck of the femur. Here the mechanism and appearance of the fracture 
are quite different in consequence of the spongy character of this portion 
of the bone. The line of fracture is transverse and upon the concave 
side, and is produced by crushing, not by over-bending. 

This fracture is seen most frequently in the bones of the forearm, then 
in the clavicle, and very rarely in the bones of the leg, arm, and thigh. 
In the forearm the convexity in the great majority of cases is upon the 
outer side, and the injury is usually the result of a fall upon the hand. 
It occurs almost exclusively in children, and between the ages of 1 and 
11 years. In a case which came under my care in 1882, the patient 
was a large stout youth of 18. His hand had been caught in machinery, 
and the forearm twisted about a large shaft ; the concavity of the curve w r as 
on the anterior and outer side, and I was unable to straighten it entirely. 

The chief symptom is deformity, consisting in a more or less marked 
change in the outline of the limb or bone, a change that can be modified 
by pressure at its most prominent point, but without crepitation and 
without abnormal mobility, except sometimes in the plane of the curve 
itself ; in the forearm, for example, the mobility is in the direction of 
flexion and extension, but is not lateral. There is also localized pain at 
the seat of the fracture. It is conceivable that this fracture might be 
produced, and that the elasticity of the bone might be sufficient to restore 
its shape immediately. The only means of diagnosis in such a case 
would be the localized pain and the history of the injury. 

The prognosis is favorable as regards healing and relief of deformity. 
Ordinarily, pressure upon the prominent point, with or without moderate 
extension, will overcome the deformity, and it has been observed in some 
cases where this could not be completely accomplished at the time that 
spontaneous restoration of form occurred within a few months. In some 
cases the deformity cannot be overcome, the bone cannot be straightened, 
because, apparently, the fragments have become so interlocked as to 
oppose a mechanical obstacle sufficient to neutralize all the force that it 
was considered justifiable to apply to the reduction. In Malgaigne's 
case he evidently, though unintentionally, transformed the partial frac- 
ture into a complete one, and I can see no reason why this should not 
always be done if necessary to obtain reduction when the deformity is 
great. If the unrelievable deformity is slight, we may safely trust to 
continuous elastic pressure by means of a splint and a roller or rubber 
bandage. 

It is not necessary that splints or other apparatus should be worn for 
the same length of time as in cases of complete fracture. The unbroken 
portion of the bone acts as a splint, and prevents displacement, but the 
same precautions must be taken against a too early or incautious use of 
the limb. 



42 VARIETIES OF FRACTURE. 

(/?) Depressions. 

These are incomplete fractures of flat bones, not involving the entire 
thickness, and accompanied by a bending of the unbroken portion, and 
a depression of the surface. The most frequent examples are presented 
by the cranial bones of new-born or young children ; the fracture is on 
the side towards which the bone is bent, and is accompanied by one or 
more fissures involving the entire thickness. Malgaigne applies the term 
also to partial fracture of the ribs, where the fracture is on the outer 
side, and is produced by crushing. The importance of the injury is 
generally due to accompanying lesions of the contained viscera, the 
brain, and the lungs in the cases just mentioned, and under such cir- 
cumstances the therapeutic indication is to raise the depressed portion 
of bone. (These must not be confounded with depressed fractures of 
the skull, in which the entire thickness of the bone is broken and 
driven in.) 

(c?) Separation of a splinter or of an apophysis. 

In this variety are included two classes of fractures, which differ 
widely in their mode of production, but have this in common that the 
fragment does not comprise the entire breadth or thickness of the bone, 
and that consequently the continuity of the latter is not destroyed. In 
the first class a splinter or fragment of bone is broken off by direct 
violence, often by a cutting instrument or by a bullet; in the second 
class a bony prominence is torn off by the violent contraction of the 
muscle or muscles attached to it. 

The separation of a splinter or scale of bone by a sword-cut or bullet 
is not uncommon in the spongy bones or the spongy extremities of long 
bones, and has also been known to occur in the shaft of the tibia. It 
is an injury which should be classed rather among wounds of bones than 
among fractures. The separation of a splinter by direct violence, unac- 
companied by a wound of the soft parts, occurs in the bones of the 
face, at the crest of the ilium, and at exposed points upon the extremi- 
ties of the long bones. Malgaigne produced it once experimentally upon 
a rib, breaking off a piece from the lower border, and he quotes from 
Dandifort the description of two specimens of splinters of the shaft of 
the femur, one an inch and a. half, the other four inches in length. 
There is no record of the manner in which the injury was produced, and 
the specimens were obtained after repair had taken place. 

Avulsion of an apophysis, or of a scale of bone, by muscular action, is 
a far more common accident than the one just described. The lesion 
consists in the fracture of an apophysis at its base, or in the tearing off 
of a portion of bone to which a muscle or tendon is attached. The frag- 
ment may consist of a thin layer of bone corresponding in extent to the 
muscular attachment and composed almost exclusively of the cortical 
substance, or it may comprise the entire thickness of an apophysis, as in 
fracture of the olecranon, of the coronoid process of the ulna, or of the 
coracoid process of the scapula. In like manner either malleolus may 
be torn off by forcibly bending the foot to the opposite side, or a condyle 
or epicondyle at the elbow or knee by forced lateral flexion of the fore- 
arm or leg, the force being exerted through the lateral ligaments. 



COMPLETE FRACTURES. 



43 



2. Complete Fractures. 

The terra complete, when applied to a fracture of a long bone, indicates 
that the bone is divided into two or more distinct fragments by a line of 
fracture crossing its long axis. 

(a) The subdivision according to the direction of the line of fracture 
has led to .much discussion, of which a large part has been wasted upon 
verbal subtilties. The old division was into transverse, oblique, and 
longitudinal fractures, names which convey the associated ideas with 
sufficient distinctness. Malgaigne undertook to limit the term transverse 
to fractures crossing the shaft of a bone at right angles to its axis — and 
presenting no marked irregularities- of outline or of surface, such a frac- 
ture, for example, as would be obtained by breaking a radish, a com- 
parison from which one of the names of this variety, fracture en rave, 
was obtained. He said he had not been able to produce such a fracture 
experimentally and had not found a specimen of one in any of the patho- 
logical museums he had examined. He claimed, therefore, that such a 
fracture did not exist, except in certain spongy bones or apophyses, such 
as the acromion, inferior maxilla, and patella, and that those which had 
been described as such were either oblique or toothed. 

The same observation had been made nearly a century before by 
Camper, as Malgaigne himself subsequently pointed out, and there can 



Fig. 6. 



Fig. 7. 





Transverse fracture of the femur. 
(Gurlt ) 



Transverse fracture of the femur. (Gurlt.) 



be no doubt but that the line of the so-called transverse fractures, is, in 
general, oblique and irregular, as claimed by these authors. But, on 
the other hand, they erred in being too absolute, for Gurlt has repre- 



44 



VARIETIES OF FRACTURE 



sented in his subsequent work several specimens, two of which are cer- 
tainly entitled to be called transverse fractures of the shaft of the femur 
in the strict sense of the term (figs. 6 and 7), and a third is a transverse 
fracture through the head of the tibia with splitting of the articular end. 
Gerdy has also described and figured a similar specimen. The variety, 
in the strict sense of the term, is, doubtless, very rare, but its existence 
cannot be denied. It merges into the oblique variety by changes in the 
general direction of the line of fracture, and into the toothed or dentate 
variety by increase in the size of the irregularities upon its surface. 
Clinically, a transverse is distinguished from an oblique fracture by the 
fact that its general direction is transverse, and prevents overlapping of 
the fragments, unless there is also associated with it a lateral displace- 
ment equal to the diameter of the bone ; and from a toothed fracture by 
the greater abnormal mobility, crepitation, and ease of reduction. 

Irregularities of outline, due to the presence of prominences of vary- 
ing height and breadth of base, are found in all fractures of the shaft of 
long bones, as might be expected from a consideration of their irregular 
shape and the variations in the thickness of their cortical layer. It is 
only when these prominences are sufficiently large to 
Fig. 8. seriously affect the degree of displacement of the 

fragments and the possibility in the completeness of 
the reduction that they deserve to be considered as 
constituting a distinct variety, the toothed fractures. 
The fact that these teeth or prominences may become 
so wedged together by the violence that causes the 
injury, that, notwithstanding the completeness of the 
fracture, its usual signs may be greatly diminished, 
or even entirely absent, is of especial importance. 
There may be no abnormal mobility, crepitation, or 
recognizable displacement, and this may lead to an 
erroneous diagnosis of simple contusion or incomplete 
fracture. It is more commonly the case, however, 
that some of the prominences are broken off, consti- 
tuting splinters, and that there is an incomplete sepa- 
ration of the fractured surfaces, a separation which it 
is always difficult and sometimes impossible to over- 
come completely on account of the interlocking of the 
smaller fragments and the prominences. 

This variety is produced more frequently by direct 
than by indirect violence or muscular action. In ex- 
periments upon cadavers it has been found that frac- 
tures produced by a heavy blow upon the shaft of 
the bone were invariably toothed and usually splin- 
tered. This fact is of value in the diagnosis, the 
difficulties of which have been already mentioned. 
In the difficult cases anassthesia may be employed 
with advantage both for making the diagnosis and 
Toothed fracture correcting the displacement, but it must be remem- 
of the femur. berecl that unless displacement exists forcible handling 



COMPLETE FRACTURES 



45 



of the parts with the object only of making an accurate diagnosis is not 
justifiable. Moderate force exerted by the hands, may be properly 



Fig. 




Fig. 10. 



Fig. 1: 



Toothed fracture of the tibia. 

employed to overcome deformity, even if it results in the fracture of 
some of the prominences, for the splinters thus produced usually remain 
adherent to the periosteum and thus preserve 
their vitality, and do not interfere with re- 
covery. 

The V-shaped fracture of the tibia, first 
described by (xosselin, 1 is an important 
variety of toothed fractures. The injury is 
generally situated in the lower half, or even 
the lower third, of the leg, and is character- 
ized by a large Y-shaped prominence upon 
the anterior and inner margin of the lower 
end of the upper fragment, and a similar one 
upon the posterior margin of the upper end 
of the lower fragment. From the depres- 
sion or re-entrant angle in the lower frag- 
ment, which corresponds to the first-men- 
tioned prominence, one or two fissures pass 
spirally downwards and often enter the 
ankle-joint. It is this fact, together with 
the difficulty of making the reduction and 
of maintaining it when made, that gives this 
variety its importance. It will be described 
more fully in connection with the other frac- 
tures of the tibia. 

An oblique fracture of a long bone is one 
in which, as the name so plainly indicates, the y. s]ia p ed fracture 
direction of the line of fracture is interme- 
diate between the longitudinal and trans- 
verse axes of the shaft. Generally speaking, fractures whose direction 



Oblique fracture 
of the humerus. 



1 Memoires de la Societie de Chimrgie, torn, v., 1855. 



46 VARIETIES OF FRACTURE. 

does not vary more than 15° or 20° from either axis are not included 
under this term ; they are classified respectively with the transverse and 
longitudinal fractures. When the deviation from the transverse axis is 
more than 45°, the fracture is named by the French authors from its re- 
semblance to the mouth-piece of a clarionet, fracture en-bec-de-fiute (fig. 
12), a fact which deserves mention only on account of the frequency with 




Oblique fracture of the clavicle. 

which the term is encountered in surgical literature. The less the obli- 
quity of the fracture, that is, the more nearly it approaches the trans- 
verse axis of the bone, the more numerous and prominent are the irregu- 
larities upon its surface and the more nearly does it coincide with the 
toothed fractures above described. The obliquity is greater when the 
fracture has been produced by indirect violence, and the smoothness of 
the surface of the more oblique fractures harmonizes, therefore, with the 
observation previously made, that toothed fractures are usually caused by 
direct violence. The greatest degrees of obliquity are found in the 
femur, tibia, and clavicle, more rarely in the arm and forearm, except, 
perhaps, just above the elbow. The especial clinical importance of the 
variety is found in the tendency of the fragments to over-ride, to undergo 
longitudinal and lateral displacements. 

Longitudinal fractures are those in which the direction of the line 
of fracture corresponds more or less accurately to that of the longitudinal 
axis of the bone. Bouisson, and after him Gurlt, have called attention 
to the fact that a division of this class into two varieties based upon 
pathological differences has an important corresponding clinical signifi- 
cance. The simplest and least dangerous kind is one that might be 
called an extremely oblique fracture, one whose direction is nearly par- 
allel to the long axis although it crosses the bone (fig. 13). The other 
and more serious kind, is that in which the main line of fracture is more 
exactly longitudinal, and terminates at one or both ends in a transverse 
or oblique line. The reason of this difference appears on examination 
of the different lesions and of the manner in which they are produced. 
Bouisson 1 produced experimentally the completest, most typical, form of 
longitudinal fracture, one running the entire length of the bone, and 
gives a figure of one in the plates attached to his work, but there is no 
record of such a fracture produced during life and verified by autopsy. 
The nearest approach to it seems to be one reported by Cloquet in 1831, 
and quoted by most subsequent writers upon the subject. The patient 

1 L'Union Medicale, 1850, and Tribut a la Chirurgie, vol. i. p. 1. 



COMPLETE FRACTURES, 



47 



fell from a roof and fractured his femur, the fracture extending from the 
intercondyloid notch to the trochanter minor; it was exactly longitudinal 
in the lower four-fifths of its length, and then deflected to terminate on 
the inner surface of the bone. A case remarkable on many accounts, 



Fig. 13. 



Fig. 14. 





Oblique fracture of the femur. 



Longitudinal fracture of the tibia. 



and apparently a longitudinal fracture of the most perfect type, was 
treated in the service of Professor Rose at Zurich, and the account pub- 
lished by his assistant, Kronlein, 1 in a paper on longitudinal fractures. 
The patient was a man, 27 years old, who received his injury in trying to 
raise a heavy ladder. The right humerus was fractured longitudinally, 
presumably through the torsion exerted by the muscles, the fracture 
running from the shoulder joint to the elbow joint. The man continued to 
work for four days ; the pain and the swelling increased, and he entered 
the hospital about a week later. Fluctuation became evident in the course 
of the second month, and evacuating incisions were made at the upper 
and lower end of the arm, through which the fracture was felt. The 
edges of the fracture became necrosed, several long sequestra were cast 
off, and the patient after passing through many complications was dis- 
charged cured at the end of two years. Both joints were firmly anky- 
losed. 

Among Bouisson's personal cases the most remarkable on many 
accounts is one that may serve as an example of the second or more dan- 
gerous kind. A man, 21 years of age, was crushed by a falling stone and 



» Deutsche Zeitschrift fur Chir., 1873, p. 132. 



48 VARIETIES OF FRACTURE. 

sustained, together with other injuries, a fracture of the femur. Three 
weeks after the accident the limb became gangrenous and amputation was 
performed high up. The femur was found to be fractured transversely 
at two points, one in the lower third, the other just below the trochanter 
minor, and the intermediate piece, which was eight inches long, was split 
longitudinally. The patient recovered. Bouisson's experiments were 
all made upon dried bones, either by subjecting them to extreme violence 
applied laterally along some prominent ridge or edge by means of a 
heavy mallet or a vise, or, in imitation of a gunshot injury, by driving 
a wedge or large nail into them. Laforgue obtained similar results by 
blows upon the lower end of the femur and upper end of the tibia in the 
direction of the long axis. The possibility of the fracture is thus estab- 
lished both clinically and experimentally, and can no longer be called in 
question. 

The simpler form is produced usually by indirect violence, and is ac- 
companied by but little splintering ; the greater gravity of the other 
form seems to be due to the direct violence which causes it, to the 
splintering, and to the crushing or bruising of the marrow, conditions 
which favor extensive suppuration, and, if the fracture is compound, will 
probably render amputation of the limb necessary. In only one of the 
cases collected by Gurlt did the patient save both limb and life, and 
in that case the fracture was purely longitudinal, without splintering, 
and without displacement. 

The diagnosis even in the simpler form may be difficult unless the 
bone is so nearly subcutaneous that the outline of the fragments can be 
felt. In the severer forms it is often impossible to this extent, that while 
the transverse fracture at either end may be distinguished, the interme- 
diate longitudinal lines may escape detection. When there has been 
much splintering, a probable diagnosis may be made by attention to the 
nature of the violence that caused the injury, the extensive swelling of 
the soft parts, the distribution of the pain over a considerable portion of 
the bone, the absence of angular displacement or of shortening, and peculi- 
arities in the position where crepitation is found and the manoeuvres by 
which it is obtained, which may indicate the extent of the fracture. 

There are no special indications for treatment except that in the 
severer cases the probable necessity of amputation must be borne in mind, 
and a decision, based upon the circumstances of each case, must be 
reached as promptly as possible 

(5) Varieties dependent upon the seat of the fracture. A fracture 
may occupy any portion of the bone or of its apophyses, and be known by 
the name of the portion fractured : thus, we speak of fractures of the 
neck of the femur, of the lower third of the tibia, of the shaft of the 
humerus, of the internal malleolus, of the outer or inner condyle, and of 
the acromion. When the fracture extends across the expanded lower end 
of the humerus or of the femur, and also downwards between the con- 
dyles into the joint, it is called inter condyloid (fig. 18), and when it 
follows, in children or adolescents, the line of the conjugal cartilage 
between the shaft of the bone and the epiphysis, it is called a separation 
or a disjunction of the epiphysis. Only the last one requires special 



COMPLETE FRACTURES. 49 

description here, intercondyloid will be spoken of in connection with the 
intra-articular fractures. 

Separation of the epiphysis. — Under this term I shall consider here 
that class of cases in which, ossification not yet having been completed, 
a transverse fracture separates the shaft of a long bone from one of its 
epiphyses. At birth the epiphyses of the main bones of the extremities 
are wholly, or almost wholly, cartilaginous, and are somewhat longer in 
proportion to the shaft than they are at the time when ossification be- 
comes complete. The line of demarcation between the epiphysis and 
the shaft is transverse, except where it is modified by the presence of 
unossified tuberosities upon the outer surface of the bone. Thus, at the 
lower end of the humerus the line bends upward to include in the epi- 
physis the outer and inner epicondyles, and at the upper end of the tibia 
it sends a tongue-shaped process downward on the anterior surface to 
include the tuberosity. Ossification begins in these epiphyses by one or 
more central points, and extends peripherally until it occupies all but a 
narrow line of cartilage at the junction with the shaft. This line is 
called the conjugal, or epiphyseal, cartilage, and the subsequent growth 
of the bone in length takes place upon its central (diaphyseal) surface. 
The surface of union between the epiphyseal cartilage and the shaft is 
apparently uniform, but the union is strengthened 
by minute interlacing prominences in such manner ff * " 

that when an epiphysis is violently separated — 
portions of the shaft of greater or less size, usu- 
ally mere scales of bone, are torn off with it. 
This fact furnishes an additional reason, if one is 
needed, for including this lesion among fractures. 
The period at which bony union between the shaft 
and the epiphysis becomes complete varies with 
the epiphysis and with the individual. The epi- 
physes Which form the elbow-joint Unite before Separation of the lower 
f * . J . epiphysis of the femur. 

those which torm the upper extremity ol the (Bryant.) 
humerus and the lower extremity of the radius ; 

while those which form the knee-joint remain ununited longer than those 
at the opposite ends of the same bones. In females all are united, as a 
rule, by the 22d year ; in males, by the 24th or 25th, yet instances are 
not lacking in which the conjugal cartilage has persisted until a much 
later period. 

Many experiments have been made to determine the degree and direc- 
tion of the force necessary to produce this fracture, and to supplement 
the scanty clinical data concerning its pathology and symptoms. In the 
very interesting chapter which Gurlt devotes to the subject may be found 
abstracts of the results obtained by different experimenters. Gurlt him- 
self was unable to separate any of the epiphyses by direct traction, as 
others had done, but he found no great difficulty in accomplishing it in 
children less than a year old by forced flexion or extension of the joint, 
especially of those joints where the normal range of motion is limited, 
the elbow and knee. He was also able to produce it by fixing the epi- 
physis, and bending the shaft in the antero-posterior, or in a lateral 
direction. In the bodies of older children he found it much more diffi- 
4 




50 VARIETIES OF FRACTURE. 

cult. Salmon 1 produced experimentally complete and incomplete sepa- 
ration, both with and without accompanying fracture of the bone. The 
periosteum sometimes remained untorn when there was no displacement 
of the fragments, but usually displacement was accompanied by the 
stripping off from the shaft of a portion of its periosteum, which re- 
mained attached to the epiphysis. The crepitation which can be obtained 
in complete separation has not the sharpness and distinctness of that 
which is found after fracture of bone ; it can be produced at the elbow 
after reduction of the displacement by rubbing the fragments quickly 
backwards and forwards against each other. 

Gurlt, in 1862, could collect only seventeen cases of separation of an 
epiphysis during life in which the diagnosis was verified by dissection ; 
of these, five were of the humerus (4 of its upper and 1 of its lower 
end), four of the lower end of the radius, five of the lower end of the 
femur, and three of the tibia. He expresses the opinion that this is a 
rare accident, and attributes its rarity to the fact that children are seldom 
exposed to the action of forces sufficiently violent to produce the sepa- 
ration. The histories of these seventeen cases show that the violence 
was much greater than that which is the usual cause of fracture at the 
corresponding periods of life. In three of the cases the fracture was 
produced during the delivery of the child by traction upon the foot, arm, 
or axilla ; in seven by severe falls ; in five the limb was caught by ma- 
chinery or between the spokes of a wagon wheel ; and in one separation 
of the upper epiphysis of the humerus was produced in a child three 
years old by jerking its arm. With the exception of the three new T - 
born children only one of the patients was less than nine years old; the 
oldest was eighteen. 

On the other hand, the opinion has been held by some that the acci- 
dent was not by any means so infrequent as the rare mention of it might 
indicate, and two papers have been published recently in support of this 
opinion. Vogi 2 reported a case in which the left humerus had become 
thirteen centimetres shorter than its fellow in consequence of an injury 
received at the age of ten years, which was probably a separation of 
the upper epiphysis. He claims that the fracture (separation) without 
displacement is common in early life, and heals promptly in children of 
strong constitutions without leaving any evil consequences, while in the 
weak and strumous it is the frequent cause of suppurative disease of 
the bone. 

Bruns 3 collected eighty-one reported cases in which the diagnosis had 
been confirmed by direct examination of the seat of injury, either 
through an associated wound or after amputation or death. In eleven 
cases the injury was double or multiple ; the total being 101, divided as 
follows : — 

1 Des solutions de continuity trauraatiques des os dans le jeune age. These de 
Paris, 1845. Quoted by Gurlt, 

2 Langenbeck's Archiv, vol. xxii. 1878, p. 343. 

3 Idem., vol. xxviL 1882, p. 240. 



COMPLETE FRACTURES. 51 

TT ( upper end 11 

Humerus { ^ i i 

( lower end -1 

Ulna \ upper end 1 

Ulna \ lower end 2 

Radius lower end 25 

Ossa pubis 3 

^ ( upper end 3 

Femur < lower end 28 



Tibia 



upper end 1 
lower end 1L 



Fibula | upper end 3 

( lower end 1 

Metatarsus 2 

101. 

In 44 cases the patients were between the ages of ten and nineteen 
years, and in 8 between one and nine, the maximum of frequency being 
at about the sixteenth year. Of 61 cases in which the exact description 
of the fracture was given, 23 were purely epiphyseal separations, 5 frac- 
tures through the cartilage, and 33 partly diaphyseal, that is, the line oi 
fracture passed through the " chondroid" tissue at the end of the diaphy- 
sis, a tissue which is partly bone and partly cartilage." 

He argues that if by a rather hurried search he was able to collect 81 
such cases, the number of simple uncomplicated fractures must be very 
much greater, and that the injury is not an uncommon one. 

My personal experience of the subject is limited to 2 cases, both com- 
pound. In one a boy thirteen years old caught his foot in machinery and 
received a compound comminuted fracture of the proximal phalange of 
the great toe ; I could see and feel through the wound the smooth carti- 
laginous disk limiting the epiphysis. The patient made a good recovery 
and had a movable joint. In the other, a child about two years old, the 
upper epiphysis of the right fibula was torn off by the wheel of a street 
car, and the knee-joint opened. The fracture was exactly at the junction 
of the epiphysis and the shaft, and the periosteum of the latter was 
entirely stripped off for some distance, remaining attached to the epiphysis. 

The symptoms in the slighter cases described by Yogt, cases which 
might be classed as partial fractures or even as sprains, are few and in- 
definite, only the limited line of pain on pressure corresponding to the 
position of the conjugal cartilage, and the general symptoms of con- 
tusion or injury near the joint. When displacement is present the diag- 
nosis of fracture is not usually difficult, its position, the cartilaginous 
crepitus, and the age of the patient are the points upon which the differ- 
ential diagnosis must be based. If at the same time the epiphysis is 
dislocated the injury may be readily mistaken for a dislocation if the 
examination is not made thoroughly. 

The prognosis in the slighter cases is favorable, in the more severe 
ones it is made grave by the severity of the associated injuries. In 
addition there is the possibility that in case of recovery the subsequent 
growth of the limb may be checked by the premature ossification of the 



QZ VARIETIES OF FRACTURE. 

cartilage. This arrest of growth is rare, and even in some of the re- 
ported cases the exact nature of the original traumatism is in doubt, for 
there is reason to believe that premature ossification of the cartilage can 
be induced by a fracture of the shaft, and the cases are quite numerous 
in which it has followed inflammation of the bone. 

Bruns reported a case in which the shortening of the humerus in an 
adult following separation of the upper epiphysis at the age of two years 
was 14 centimetres. Bryant 1 speaks of one in which the shortening of 
the humerus amounted to five inches, and of another (loc. cit., p. 854) 
in which the shortening of the tibia amounted to an inch in two years in 
a child eight years old. Other cases are quoted by Vogt and Bruns. 

The principal reason of this non-interference with the growth in most 
cases appears to be in the frequent situation of the line of fracture in 
the layer of partly formed bone adjoining the cartilage. The osteogenic 
layer itself is not directly involved and its function is not interfered with. 
Another fact, which is a reason why the interference should not be noticed 
rather than why it should not occur, is that the injury is by far most 
frequent at an age when the growth of the skeleton is almost completed, 
and when the result of an arrest of growth, in the upper extremity at 
least, might easily pass unnoticed. In cases mentioned by Gurlt and 
Hamilton union failed and a false joint formed, and in one reported by 
Esmarch 2 a large abscess formed, and led to the removal of the epiphy- 
sis and a portion of the shaft (upper end of the humerus); the injury 
had been mistaken for a dislocation of the shoulder, and two attempts 
had been made to reduce it. 

The treatment requires no especial mention here. It is the same as 
that of other fractures in the same region, and will be described in con- 
nection with the special injuries of the different bones. 

(<?) Intra-articular Fractures. — The proximity of a fracture to a joint 
is always of importance on account of the possibility of the direct im- 
plication of the latter in the injury or in the subsequent inflammatory 
process to which the injury gives rise. The arthritis which may be 
thus set up adds greatly to the sufferings of the patient, complicates the 
treatment and endangers the integrity of the functions of the joint. 
The danger is greatest when the fracture extends directly through the 
bone into the joint, and to this variety is given the name intra-articular. 
The converse term extra-articular is applied to those fractures which are 
not thus complicated, but whose seat is sufficiently near an articulation 
to raise the question of the possible communication of the fracture with it. 

A fracture of the shaft of a bone may be made intra-articular by a 
fissure extending into the joint, as in the V-shaped fractures of the tibia 
and in some gunshot fractures, but much more commonly the main line of 
fracture involves a portion of the expanded articular extremity of a bone 
lying partly within the capsule, as in fractures of the condyles of the 
humerus or femur. Complete fractures of the patella and olecranon are 
necessarily intra-articular. 

A special signification of the term when applied to fractures of the 

> Surgery, 3d. Am. ed., p. 834. 

2 Arcliiv t'lir Klin. Cliirurgie, vol. xxi. 1878. 



COMPLETE FRACTURES. 



53 



Fig. 16. 




femur must be noted. An intra-articular fracture of the neck of the 
femur is one in which the line of fracture lies entirely within the cap- 
sule; when the fracture is entirely external to the attachment of the 
capsule it is called extra-articular, and when partly within and partly 
without it is called a mixed fracture. In like manner we speak also of 
an intra-articular fracture of the neck of the humerus, meaning one that 
lies entirely within the capsule. 

Intra-articular fractures owe their importance to their special ana- 
tomical conditions which retard the process of repair, introduce arthritic 
complications, make proper treatment more 
difficult, and affect the prognosis. These 
special conditions are the communication, 
usually free, between the seat of fracture and 
the cavity of the joint, the injury to the ar- 
ticular cartilage and the capsule, and in most 
cases the small size of the fragment which 
makes it difficult or impossible to apply an 
efficient retentive apparatus. 

The effect of communication betw r een the 
seat of fracture and the cavity of the joint is 
that the surface of the former is constantly 
bathed in the sero-sanguinolent liquid that 
fills the latter, the lymph which ought to aid 
in the formation of granulations to unite the 
broken pieces, is diluted and washed away, 
so that union, if not prevented entirely, is 
likely to be fibrous. The fibrous character 
of the union which is so frequent under these 

circumstances has been thought to be due to the specific action of the 
synovial liquid upon the granulations, but the opinion has not been sup- 
ported by satisfactory proof. The single case reported by Jarjavay and 
quoted by Follin 1 may have been merely a coincidence. It was that of 
a man 45 years old, who died of an intercurrent affection on the 42d 
day after he had fractured the external malleolus. The autopsy showed 
entire absence of inflammation in the joint or bone ; the fragments were 
in good position, and were united by a fibrous- band which presented no 
trace of cartilaginous or bony structure. Those who claim that the ab- 
sence of bony union in this case was clue to the contact of the synovia, 
overlook the possibility that it may have been a simple coincidence, and 
that fibrous union sometimes occurs where this agency is certainly not 
involved. Sometimes an osteitis is set up in the fragments which, when 
added to the pre-existing synovitis, is sufficient to cause necrosis of the 
articular cartilage and probably destroy the future usefulness of the joint. 

The injury to the other constituent parts of the joint excites therein 
an inflammatory process which is usually acute, and may end in suppu- 
ration ; in any case it is followed by a thickening and loss of pliability 
in the capsule and periarticular tissues, and possibly by the formation of 
intra-articular bands between the opposing surfaces of bone or capsule, 



Intra-articular fracture of the 
head of the tibia, with impaction 
aud separation of the upper frag- 
ments. 



1 Pathologie externe, vol. ii. p. 757. 



54 



VARIETIES OF FRACTURE 



which may permanently restrict the range of motion. An acute arthritis 
in a large joint is always a serious affection, full of danger to the limb, 
and even to the life of the patient. 

Displacement of the fragments after fracture of the articular end of a 
long bone, as, for example, of either condyle of the humerus or femur, 
is favored by the action of the attached muscles, and is difficult to oppose 
because the fragment is too small to be controlled by the dressing. 
When the fracture is not only intra-articular but also intercondyloid, 
that is, when both condyles are separated from the shaft and also from 
each other, this difficulty is much increased ; the two fragments separate 
laterally, and the other member of the joint is drawn up by the tonicity 
of the muscles into the interval between them. Consequently, when 
union has taken place the functions of the joint are found to be diminished, 
or entirely destroyed, by the change in the relations of the articular 



Fig. 17, 



Fig. IS. 





Intra-articular fracture of the lower end 
of the humerus, with exuberant cailus, 
especially in front. 



Intercondyloid fracture of the humerus 



surfaces to each other, or by overgrowth of the callus in the interval. 
In young people who have not yet reached their full stature, and whose 
bones are prone to excessive and irregular formation of callus, this is a 
frequent cause of crippling, especially at the elbow, where the callus 
may fill up the olecranon or the coronoid fossa and oppose an insur- 
mountable mechanical obstacle to the movements of flexion and exten- 
sion. These changes will be studied more fully in connection with the 
subject of repair of fractures. 

The diagnosis in the case of a simple fissure extending from the frac- 
ture to the joint can be based upon the nature of the main fracture, upon 
the fact that certain kinds are usually complicated by fissure, and upon 
the occurrence of inflammation within the joint ; in the other cases, 
where the fracture occupies the articular end of the bone, it is made by 
recognition of the size and shape of the fragment and of the deformity. 



MULTIPLE FRACTURES 



55 



It often happens that blood escapes so freely from the torn vessels that 
it fills up the cavity of the capsule, and by preventing palpation of the 
bony parts makes an exact diagnosis very difficult. 



3. Multiple Fractures. 

Under this term are included simultaneous fractures of two or more 
bones in different parts of the body, and two or more fractures of the 
same bone at different points. The latter variety passes by gradations in 
the size and number of the fragments into that known as comminuted 
fracture, which will therefore also be considered under this head. The 
simultaneous fracture of both bones of the forearm, or of the leg, is not 
called a multiple fracture, and Malgaigne also excludes from this class 
the fracture of two or more adjoining ribs. 

The simultaneous fracture of two or more bones may be produced by 
a great variety of causes, and its importance, so far at least as the life of 
the patient is concerned, depends largely upon the immediate cause of 
the injury. When this cause, as is so frequently the case, is found in 
the action upon the body of extreme violence, as in a fall from a great 
height, the explosion of a boiler or of a blast, the caving in of an em- 
bankment, or the fall of a heavy block of stone, it often involves such 
serious injury to other organs, or so much shock to the system, that 
death terminates the case promptly; or the local injury is so great that 
the surgeon is called upon, not to treat a fracture, but to perform an 
amputation. When, on the other hand, the fractures are caused by a 
moderate violence exerted only upon the limbs which are broken, the 
prognosis is not much more unfavorable than in similar single fractures. 
Dupuytren first called attention to the fact that while the danger of 
wounds and fractures is undoubtedly greater when they are numerous, 
yet it does not increase in direct proportion to their number ; on the 
contrary, when there are several fractures each one runs a milder course 
in general than if it were single. Malgaigne and V alette repeat and 
confirm this statement so far as it relates to simple fractures, and the 
former suggests as a possible explanation, that when the vital force is 
thus distributed among several points, it cannot excite as much reaction 
at each as it could do if confined to a single one. 

In Malgaigne's list of 2358 fractures there were 30 patients present- 
ing 67 fractures, counting those of both bones of the leg or forearm or 
of several ribs as one. They were distributed as follows : One patient 
having 4, six having 3, and the rest 2 apiece. 



Fractures 


of the leg .... 


26 


i . 


" thigh .... 


14 


a 


u arm .... 


7 


u 


" head . . . . 


7 


U 


" clavicle . . 


4 


u 


''- forearm 


3 


a 


" vertebral column . 


3 


Scattering 




3 



56 



VARIETIES OF FRACTURE. 



Fracture of a single bone at two separate points is an injury of rare 
occurrence. The fractures may occupy the shaft alone, or the shaft and 
one epiphysis (fig. 19), or both epiphyses (fig. 20). So far as known 
such fractures have been produced only by direct violence, usually a 



Fig. 19. 



Fig. 20. 





Multiple fractures of both, bones of the 1< 



Multiple fracture of the fibula, 



crushing force exerted by a large and heavy body. Sir Astley Cooper 1 
reported a case of double fracture of the shaft of the humerus in a man 
seventy-one years old by a fall against the edge of a curbstone. 

Multiple fractures characterized by communicating lines of fracture 
and the consequent production of several fragments of large size are 
much more common, and are found in the shafts and epiphyses of long 
bones and also in short bones. They may be produced by indirect as 
well as by direct violence, and in their simpler foruis are usually the re- 
sult either of the breaking off of some of the prominences of an oblique 
or dentate fracture, or of the splintering action exerted upon an epiphy- 
sis by the broken end of the shaft. These fragments exert an important 
influence upon the course and termination of the case ; if numerous, and 
if separated also more or less completely from the periosteum through 
which alone their nourishment can be assured, they may act as foreign 
bodies, excite suppuration, and finally be expelled, sometimes only after 
the lapse of several years. By becoming lodged between the principal 



Guy's Hosp. Reports, vol. iv. 1839. 



MULTIPLE FRACTURES. 57 

fragments of the shaft of a bone they may prevent complete reduction 
of the displacement, and render a certain amount of deformity or short- 
ening unavoidable ; and when formed by portions of the articular end of 
a bone they are almost certain to interfere seriously with the future use- 
fulness of the joint by modifying the relations of its opposing surfaces. 

Comminuted Fractures. — Strictly speaking, a comminuted fracture is 
one in which a portion of a bone is broken up into small fragments, and 
in that sense the term is now generally understood, although Dr. Hamil- 
ton 1 uses it as a synonym of multiple, without regard to the size of the 
pieces. That the classification is somewhat vague, and that the boun- 
dary-line between this variety and that of multiple fractures is uncer- 
tain, is the natural result of the innumerable gradations in size between 
the largest and the smallest fragments, and of *the frequent combination 
of widely different sizes in a single case, but fortunately this is without 
importance. This variety also includes impacted fractures and fractures 
with crushing, which are of frequent occurrence in the expanded ends of 
the long bones, especially in the old, and are usually accompanied by 
absolute loss or destruction of a considerable amount of the spongy 
tissue. 

Comminuted fractures present notable differences in the size and num- 
ber of the fragments and in their relations to each other and the sur- 
rounding soft parts. A bone may be broken into many fragments, and 
yet the relations of the pieces may be well preserved by the support 
given to them by the periosteum and adjoining tissues. This is especi- 
ally the case in the short bones and in the spongy portions of the long 
ones. On the other hand, the fragments may be so numerous and so 
thoroughly detached, and the surrounding muscles so crushed and torn, 
that the limb feels like a bag full of bones ; or one of the fragments may 
be driven into another and impacted among the pieces into which the 
latter is split. Under these last conditions the limb is shortened, but ab- 
normal mobility and crepitation may both be prevented by the firmness 
with which the fragments are wedged together. Permanent deformity 
is rendered inevitable by the separation of the fragments and the de- 
struction of a certain amount of the spongy tissue. 

When the bone has undergone the common senile change character- 
ized by rarefaction of its spongy tissue, interstitial atrophy, this impac- 
tion may take place without splitting, but with crushing and practical 
destruction or condensation of a portion of one or both fragments, and 
a similar effect is sometimes produced in the short bones without impac- 
tion ; the bone is simply crushed together or compressed. This is the 
so-called fracture ivith crushing, and, although most common in ad- 
vanced life, is frequently seen in the vertebrae without senile change. 
The meshes of the spongy tissue, which are filled with fat and bounded 
by thin lamellae of bone, are broken down and their contents squeezed out, 
so that an absolute and often considerable loss of substance results, which, 
if not made good by the formation of new bone, leads inevitably to a 
permanent deformity, or to a failure of union between the principal frag- 
ments. 

1 Fractures and Dislocations, 3d ed. p. 27. 



58 



VARIETIES OF FRACTURE. 



The cause of comminuted fractures of the shaft of long bones is 
usually direct violence, such as the passage across the limb of a loaded 



Fig. 21. 




Fig. 22. 




Comminuted fracture of the femur, with 
splitting of the condyles. 



Comminuted fracture of the neck of the femur. 



wagon or the fall of a heavy body ; in the spongy bones of the foot, or 
in the vertebrse, it is sometimes produced by a fall upon the feet from a 
height, and in the expanded ends of the long bones by either direct or 



Fig. 23. 



Fig. 24. 





Comminuted fracture of the lower end 
of the radius. Palmar aspect. 



Impacted fracture of the neck of the femur 
without splintering. Vertical section. 



indirect violence. On the other hand, a comminuted fracture of the 
neck of the humerus or femur can be produced in persons whose bones 
have undergone senile change by very slight causes, such as a misstep 



COMPOUND FRACTURES. 59 

or a fall upon the floor while walking. When the injury is caused by 
direct violence, the soft parts are usually involved to such an extent that 
the fracture is, or soon becomes, a compound one. In the treatment of 
compound comminuted fractures, only such fragments should be removed 
at the first dressing as are entirely loose in the wound or but very 
slightly attached. 

A positive diagnosis of comminution may sometimes be made by direct 
exploration of the seat of fracture through an accompanying wound, 
or by palpation of the fragments where the bone is subcutaneous. Under 
other conditions the surgeon must often be content with a " probable" 
diagnosis based upon the nature and mode of action of the causative vio- 
lence, upon the seat of the fracture, and upon the age of the patient. 

4. Compound Fractures. 

A compound fracture is one in which communication between the seat 
of fracture and the external air is established through a wound of the 
soft parts. The existence of this communication has an important influ- 
ence upon the prognosis, one that depends not upon the simple addition 
of another traumatism, or upon the greater violence that has caused the 
fracture, but upon the modification which the contact of the air produces in 
the process of repair and upon the train of serious complications which may 
result. The difference between simple and compound fractures is similar 
to that which exists between subcutaneous and open wounds ; in the 
former, recovery takes place in the great majority of cases speedily and 
without suppuration ; in the latter, suppuration is often inevitable, and 
the patient is exposed to all the complications to which it may give rise 
or for which it may furnish the opportunity. It is not the simple addi- 
tion of an external wound that introduces the element of danger, but it 
is the communication between the two and the consequent possibility of 
a change in the character of the reparative process at the seat of frac- 
ture, of irritation of the medullary and spongy tissue of the bone, of de- 
composition of the discharges, and of the absorption of the products of 
this decomposition which is specially favored by the presence of an open 
medullary canal, and by the difficulty of properly draining the irregular 
and deeply situated cavity. A coexistent wound of the soft parts which 
does not communicate with the fracture, even if in its immediate neigh- 
borhood, does not create the same danger, and does not entitle the frac- 
ture to be called compound ; the fracture remains a simple one and pur- 
sues the usual course, the wound usually having no more effect upon it 
than if it were at a distance, except in so far as it may interfere with 
the application of a splint. An additional element of danger arises from 
the usually greater causative violence, and lies in the greater probability 
of the coexistence of other complications, such as hemorrhage from a 
wounded vein or artery, rupture of a nerve, or communication of the 
fracture with a neighboring joint. 

It is impossible to make an exact statistical statement of the prognosis 
in compound fractures, for the reason, among others, that the results ob- 
tained in different hospitals vary widely. It is unquestionable that of 
late years, especially since the more general adoption of antiseptic treat- 



60 VARIETIES OF FRACTURE. 

ment and the greater care and attention given to obtaining thorough drain- 
age and maintaining cleanliness of the wounds which the discussion of 
that subject has produced, the results have been much improved. It 
seems hardly probable that the experience of Volkmann, who, previous to 
1873, lost by death three out of every four cases of compound fracture 
in his hospital service, will ever be repeated ; while, on the other hand, the 
most perfect treatment will not always obviate the necessity for amputa- 
tion or the risks of hemorrhage, shock, and delirium. As an evidence 
of what may be obtained by antiseptic treatment, I may quote Mr. Mac- 
Cormac's report 1 of sixteen successive cases of compound fractures, 2 of 
the femur, 3 of the upper extremity, and 11 of the tibia, thus treated, 
which furnished fourteen recoveries, one amputation, and one still under 
treatment for delayed union. Yolkmann, 2 in his address on Surgery be- 
fore the International Medical Congress in 1881, said he had treated 
antiseptically 135 successive compound fractures ; 133 recovered, 1 died 
of fat embolism, and 1 of delirium tremens. 

Compound fractures are most frequent in the lower extremity, and 
comprise, according to Gurlt, nearly 16 per cent, of all fractures of the 
limbs. Excluding fractures of the metacarpal and metatarsal bones and 
phalanges, they occur most frequently in both bones of the leg, 17.96 
per cent. ; then in both bones of the forearm, 11.68 per cent. ; then in the 
shaft of the femur, 7.05 per cent.; and then in the humerus, 6.66 per 
cent. They are most dangerous when the bone is deeply covered by the 
soft parts, least dangerous when it is subcutaneous. 

They are produced by both direct and indirect violence, but more 
frequently by the former than by the latter, and in that case are much 
more rarely accompanied by clean-cut wounds than by bruising and 
crushing of the soft parts. The communicating wound may be made 
from without inwards, or from within outwards ; in the former manner, 
when the violence is direct, by immediate division of the soft parts down 
to the bone, or by their subsequent sloughing in consequence of- the 
contusion they have received ; from within outwards when the end of 
one of the fragments is forced through the skin, or when, in the case of 
an intra-articular fracture with accompanying dislocation, the skin is 
broken by being stretched across one of the bony edges or prominences 
of the joint. In both these latter cases the bone projects through the 
opening in the skin, which is usually small enough to grasp it tightly. 

A fracture that is simple at first may be made compound by the 
sloughing of the skin over the projecting end of a fragment which can- 
not be properly reduced, or by the subsequent forcing of a fragment 
through the skin by the careless handling of those who first come to the 
patient's aid, or by his own act during delirium, or while still in igno- 
rance of the nature of the injury he has just received. Thus, Ambroise 
Pare, having had his leg broken by the kick of a horse, stepped quickly 
backward, and bringing his weight upon the broken limb forced the end 
of one of the fragments through the skin. The English surgeon, Pott, 
appreciated this danger so fully, that when he suffered the fracture at 

1 British Medical Journal, December 6, 1879, p. 907 

2 Lancet, August 13, 1881, p. 283. 



COMPOUND FRACTURES. 61 

the ankle which is now known by his name, he refused to allow him- 
self to be raised from the ground until a shutter had been brought upon 
which he could be carried. Gurlt 1 quotes three singular cases in which 
a piece of the projecting bone was broken off outside the body. In one 
of them the end of the humerus, broken by a fall from the mast, was 
forced half an inch into the planking of the deck, and a piece of the 
bone three inches long broken off"; in another a piece of one of the 
bones of the leg more than an inch long was broken off in the ground by 
contact with a stone ; and in the third a piece of the femur, two and 
three-quarter inches long and three-quarters of an inch thick, comprising 
half the thickness of shaft of the bone, was found in the patient's 
trousers after a fall from a height of twenty feet. All three cases re- 
covered, the last one with an angular displacement for which the patient 
underwent re-fracture at the hands of Langenbeck. 

When the bone projects, or can be seen through the wound, there is 
of course no difficulty in making the diagnosis. But it is not always so 
easy. The coexistence of a fracture with the recognized wound of 
the soft parts may be determined by the usual diagnostic methods, and 
then the question arises whether or not they communicate with each 
other. If the wound is large, ragged, and badly bruised, the finger or 
a probe may be cautiously introduced to feel for bare bone, but as a 
rule, such explorations are rather to be avoided. If the doubt cannot 
be otherwise cleared up it is better to consider the fracture a compound 
one, and treat it accordingly : if it proves not to be one, no harm is 
done ; while if it is compound, the only advantage of such an exploration 
would be the recognition of fragments that might need to be removed, a 
rather rare contingency. There are two other symptoms that have a 
certain diagnostic value, although they are not absolutely pathognomo- 
nic ; hemorrhage and the admixture with it of drops of fat continuing 
for several hours after the receipt of the injury. Hemorrhage from the 
soft tissues alone, unless arterial, does not usually last long, and if arte- 
rial can be recognized by its color, while the bleeding from a broken 
bone is always more profuse and long continued. Drops of fat seen in 
the blood immediately after the accident may have come from the sub 
cutaneous tissue, but those which appear after the lapse of several hours 
are much more likely to have come from the marrow of the bone. 

The treatment is the same as that of other fractures, with the addition 
of such measures as are rendered necessary by the wound of the soft 
parts, and it cannot be too strenuously urged that whenever there is any 
hope of obtaining primary union of the wound the attempt should be 
most carefully made, for if it succeeds the fracture becomes a simple 
one and pursues the usual course of such fractures. When the wound 
is small and clean-cut, especially if it has been made from within out- 
wards, the surrounding skin should be thoroughly washed with disinfect- 
ants after reduction has been made, and the limb has been placed in a 
retentive apparatus, and then the wound should be covered with a piece 
of gold-beater's skin, oil-silk, or thin rubber cloth fastened down on 
three sides by means of collodion. The fourth side, which should be 

1 Loc. cit., vol. i. p. 69. 



62 VARIETIES OF FRACTURE. 

the dependent one, is left open in order that the blood or discharges may 
drain away. Then compresses wet with carbolized water should be laid 
over the wound, and renewed as often as is necessary to prevent decom- 
position. By this means the wound can be watched as well as if it were 
exposed, and it is at the same time kept aseptic. This is a modification, 
introduced by Verneuil, 1 of the old method of treatment by occlusion, 
and renders it more certain as well as applicable to a larger number of 
cases. Even if the wound of the skin suppurates, primary union may 
take place in the deeper portions and serve the same important purpose 
of rendering the fracture simple instead of compound. 

If the soft parts are crushed or a joint largely opened, so that primary 
union is not to be hoped for, the fracture must be reduced, and the limb 
perfectly immobilized in an apparatus that will permit the wound to be 
properly dressed, and by a proper dressing is meant one that secures 
drainage and cleanliness. The full Lister method is to be highly recom- 
mended, but if it is not practicable the surgeon may still hope to obtain 
an equally good result by the free use of carbolic acid and close atten- 
tion to the wound. Prof. Markoe 2 has recently introduced a method 
which has given excellent results both in his hands and in those of others. 
He passes drainage-tubes through the wound and counter-openings made 
for the purpose, and injects a 2 J-per cent, solution of carbolic acid three 
or four times each day. He thinks the carbolic acid has a desirable 
topical effect upon the wounded tissues and favors healing in this man- 
ner as well as by preventing decomposition of the discharges. If the 
wound can be kept aseptic, the dangers of an unsuccessful attempt to 
save the limb are greatly diminished, and the patient is likely to reach 
the period when a secondary amputation or excision can be performed 
with a good prospect of success. By the use of antiseptic measures the 
surgeon may be often spared the necessity of deciding promptly upon 
an amputation, a decision which in doubtful cases is always the source 
of great anxiety, and, when not accepted by the patient, is liable to give 
rise to unjust and unfavorable comment if he is fortunate enough to 
escape with his limb and life. 

5. Gunshot Fractures. 

Gunshot fractures are a variety of compound fractures entitled to 
separate consideration, not merely by reason of the special nature of the 
violence that produces them, but also on account of their severity, their 
numerous complications, and their grave prognosis. In speaking of them 
as compound fractures the fact that in rare instances a spent ball or 
fragment of shell may cause a simple fracture is not overlooked, but 
these cases, although literally gunshot fractures by virtue of their cause, 
belong more properly to some of the other classes, and have but little 
in common with the much more grave ones that have a similar origin. 

Gunshot fractures may occur in any part of the skeleton, but those 
which involve the bones of the cranium or the trunk are generally asso- 
ciated with visceral lesions that are either promptly fatal or of such 

1 Memoires de Chirurgie, vol. ii. p. 271. 

2 Am. Journ. Med. Sciences, April, 1880. 



.GUNSHOT FRACTURES. 



63 



importance that the fracture itself becomes a matter of secondary con- 
sideration. The fracture, when it involves a long bone, may be either 
partial or complete ; in the former case large or small splinters are 



Fig. 25.1 



Fie. 26. 5 



Fig. 27. 1 





Partial fractvu 



Perforating gunshot frac- 
tures of the lower third of the 
humerus. 



'& ..:. 



Gunshot fracture 
of the humerus. 



broken off by a ball which strikes some project- 
ing portion of the bone, or glances from its shaft 
(fig. 25), or, more rarely, perforates it entirely 
without destroying its continuity. The complete frac- 
tures usually show an extreme degree of comminution, 
with long fissures running up and down the shaft 
(figs. 26, 27, 28). Usually the ball passes entirely 
through and beyond the bone, but sometimes fails to 
do so, and then lies loose in the adjoining tissues or impacted among 
the fragments (fig. 29). It occasionally happens in the smaller long 
bones, such as the fibula or the metacarpal bones, that the ball carries away 
a complete segment of the shaft, and thus creates a gap between the 
ends of the two main fragments that prevents their subsequent reunion. 
These are sometimes called " resection fractures." The gravity of shot 
fractures is due in great part to the degree of comminution, and to the 
fissures which insure the implication of the marrow in the traumatism to 
so considerable a distance ; the resulting osteo-myelitis increases the 
chances of pyaemia, and may lead to necrosis of the shaft of the bone 
and prolonged suppuration, which ends in amputation or in the death of 
the patient by exhaustion. 

The soft parts about the track of the ball are always so bruised and 
torn that sloughing and suppuration are inevitable ; and in civil practice, 
where the injury is much more commonly caused by the discharge of a 



1 From Med. and Sure. Hist, of the War of the Rebellion. 



64 



VARIETIES OF FRACTURE 



shotgun at short range than by a rifle ball, the destruction of tissue 
is exceptionally great. The proportion of serious associated injuries to 
the nerves and bloodvessels is greater than in compound fractures due to 
other causes, and they are especially liable to declare themselves by 



Fisr. 28. 



Fis. 29. 





Comminuted gunshot fracture of the head of the 
humerus. (U. S. Med. & Surg. Hist ) 



Gunshot fracture of the head of the humerus 
with impacted ball. (TJ. S. Med. & Surg, Hist.) 



secondary hemorrhages, the result of the sloughing of vessels that have 
been bruised but not immediately divided by the projectile, or that have 
ulcerated from prolonged contact with the ball, or a portion of clothing, 
or a fragment of bone. Another important and frequent complication is 
the implication of a joint by extension of a fissure to it, a complication 
which may be even more serious in its consequences than if the articular 
end of the bone were itself the seat of the principal injury, for it may 
lead to a secondary amputation, whereas under the other circumstances 
a useful limb may be preserved by resection of the joint, or a primary 
amputation be performed with a better prospect of success. 

The treatment and prognosis of gunshot fracture have been established 
mainly by the results of military surgery, and are not, perhaps, entirely 
applicable to cases occurring in civil practice, because the exigencies of 
the field of battle, the lack of opportunity for the care and precautions 
that should be immediately taken, the exposure often prolonged, the 
necessity for repeated transport over bad roads, the crowded hospitals, 
and the inability of the overworked surgeons and nurses to give each 
case the attentive personal care which is so desirable, combine to often 
force an amputation where, under more favorable circumstances, conser- 
vative treatment might be successful. The indications also are that the 
use of carbolized dressings will have the same effect in improving the 
prognosis with respect to both life and limb in this class of cases that it has 
had already in others. 1 The choice of treatment lies between amputation, 
excision of a joint, and pure conservative treatment in which the inter- 
ference is limited to removal of foreign bodies, provision for thorough 

1 See some remarkable cases of conservative treatment after gunshot wounds of 
joints in the Russo-Turkish War of 1878-79 in MacCormac's address, loc. cit., and 
in his Antiseptic Surgery, Smith, Elder & Co., 1880, p. 41. 



GUNSHOT FRACTURES. 65 

drainage, and giving exit to pus and splinters when they present them- 
selves. The question will be considered more in detail in the chapter 
on Treatment, and I shall limit myself here mainly to the restatement 
of some of the conclusions arrived at by Mr. Longmore, 1 Professor of 
Military Surgery at Netley, by Professor Langenbeck, 2 and Colonel 
Otis, the editor of the Medical and Surgical History of the War of the 
Rebellion. It must be borne in mind, however, that since these opinions 
were expressed the antiseptic methods of treatment have singularly di- 
minished the necessity for sacrificing limbs to save life. 

All authorities recognize the danger of operations undertaken during the 
intermediary period, that is, during the stage of inflammation and infiltra- 
tion of the soft parts, which begins from twenty-four to forty-eight hours 
after the receipt of the injury and lasts until the acute inflammatory pro- 
cesses have terminated in convalescence or in chronic suppuration. An 
operation therefore must be done at once, or postponed for three or more 
weeks. Colonel Otis gives the preference unhesitatingly to the primary 
operation, and so does Mr. Longmore in amputations, while Langenbeck 
recommends quite as strongly secondary excision of the shoulder and 
ankle joints, except in rare cases and primary excision of the elbow and 
possibly of the wrist. 

Excision is to be preferred to amputation after shot fracture of the 
upper articular extremity of the humerus, when the main vessels and 
nerves are uninjured ; and Langenbeck reports two cases to show that 
extensive laceration of the soft parts is not a contra-indication. For in- 
jury of the shaft of the humerus amputation in continuity when possible 
is always to be preferred to disarticulation, and the United States 
Reports show very positively that amputation in the lower third is much 
more fatal than amputation at a higher point, or even than disarticulation 
at the shoulder. 

At the elbow the danger of conservative treatment or delayed opera- 
tion lies in the facility with which suppuration spreads among the mus- 
cles of the forearm, and the disability of the hand which results from 
this, and the necessary evacuating incisions by reason of adhesions 
among the tendons. Moreover, conservative treatment, if successful, 
ends inevitably in ankylosis of the joint. If the vascular and nerve 
supply of the forearm is uninjured an attempt therefore should be made 
to save the limb by excision. 

Primary amputation of the forearm is condemned by Colonel Otis, 
"except in rare cases where the tissues are almost disorganized," and 
he expresses the most unqualified disapproval of the excision of portions 
of the shafts of these bones. The same w T riter says it is still uncertain 
whether or not excision of the wrist for injury is a proper operation, and 
Longmore expresses a doubt whether a satisfactory result is ever possible, 
but Langenbeck says, 3 that when the epiphyses of the radius and ulna 
and the carpal bones are shattered, especially if the ball has lodged in 
the wound, primary excision is certainly indicated ; while after simple 

1 Holmes's System of Surgery, vol. ii. 1870. 

2 Archiv fur Klin. Chirurg., vol. xvi. 1874. 

3 Loe. eit., p. 462. 



66 VARIETIES OF FRACTURE. 

perforation of the wrist, he would treat conservatively, and resect with- 
out delay whenever commencing infiltration of the forearm could not be 
checked by incisions. 

After shot fractures of the upper articular end of the femur, primary 
amputation has proved so fatal that it is now practically abandoned, and 
the choice lies between conservative treatment and excision. Both mea- 
sures have yielded a small proportion of successes. In those of the 
upper third, where the joint was not involved, the results of conservative 
treatment have been a little less bad than those of amputation. Shot 
fracture of the middle and lower thirds of the femur calls, as a rule, for 
primary amputation, for conservative treatment has furnished a conside- 
rably larger percentage of mortality. 

In fractures of the leg involving the knee-joint experience shows am- 
putation to be by far the safest treatment. Excision has given very bad 
results, which Langenbeck, however, thinks might be improved by the 
use of the immovable plaster splint. Conservative antiseptic treatment 
has recently furnished results which, if confirmed by further experience, 
will reverse this conclusion. Dr. Reyher, a surgeon in the Russian 
army operating in the Caucasus, reports eighteen cases of gunshot 
wound of the knee-joint treated conservatively and antiseptically, with 
only three deaths. 1 The limb was saved in fifteen cases, and with a 
movable joint. Fractures of the leg not involving either joint have done 
well under conservative treatment. Fractures of the ankle have been 
thought to require immediate amputation, and excision has been but re- 
cently introduced and rarely tried. Its results have not been very good, 
but Langenbeck nevertheless thinks that what he calls the " conservative 
expectant" treatment should be more generally employed, because the 
superficial position of the bone allows free incisions and ready extrac- 
tion of splinters, and the tendons do not need to be carefully preserved, 
since ankylosis, with the foot in a good position, should be the result 
sought for. Immobilization in a plaster splint is essential, with the foot 
at right angles to the leg, and without any deviation about its own lon- 
gitudinal axis. 

If conservative treatment of a gunshot fracture is determined upon, 
the limb must be immobilized as completely as possible, foreign bodies 
and detached splinters removed from the wound, and drainage secured 
by counter-openings if necessary. The weight of testimony is against 
interference with attached splinters, or the removal of the sharp ends of 
the principal fragments. 

1 Volkmann's Sammlung Klinischer Vortrage, Aug. 1878 ; quoted by MacCormac, 
loc. cit. p. 41. 



DISPLACEMENTS. 67 



CHAPTER III. 

DISPLACEMENTS. 

The relations of the two principal fragments produced by fracture of 
a bone may be altered in various ways, which Malgaigne classifies under 
six heads. This classification has been generally adopted, with the un- 
derstanding, however, that a fracture usually presents a combination of 
two or more of them, and that there is an additional group of cases in 
which the number of the fragments and the character of the displace- 
ment are such as to defy classification. Under exceptional circumstances, 
as when the periosteum is not torn, or when the broken bone is one of a 
pair, displacement may be entirely lacking. 

These six classes include displacements according to : — 

1st. The transverse axis of the bone, transverse or lateral displace- 
ment. 

2d. The long axis of the bone, angular displacement. 

3d. The circumference of the bone, rotatory displacement. 

4th. The length of the bone, overriding. 

5th. Penetration of one fragment by the other, impaction or crushing. 

6th. Direct longitudinal separation. 

1. Transverse or lateral displacement may take place forward, back- 
ward, or toward either side, and may be partial to any degree, or com- 
plete. In the latter case, that is, when the displacement equals the 
transverse diameter of the bone and the broken surfaces are no longer in 
contact with each other, the tonicity of the muscles draws the fragments 
past each other and adds overriding to the lateral displacement unless 
prevented by the presence of a collateral bone, as in the forearm or leg. 
Pure transverse displacement is rare, and practically may be said to 
occur only in transverse or dentate fractures. It is usually associated 
with longitudinal or angular displacement or both, as shown in figs. 
30 and 31. When the bone is subcutaneous and the fracture very re- 
cent the displacement may be recognized by the eye or the finger, but 
when the bone is covered by thick muscles or hidden by inflammatory 
swelling the displacement can only be inferred from the coexistence of 
another. Malgaigne mentions a case in which a large clot of blood two 
inches above the patella was mistaken by him for the projecting end of 
a broken femur. 

2. Angular displacement may vary in degree from a slight deviation, 
as in fig. 32, to a right angle, or even more, and may be associated 
with so complete and distant separation of the broken surfaces that the 
fragments form a T, as in figs. 34 and 35. It may sometimes be recog- 
nized by the eye, and it causes an amount of shortening which varies 



68 



DISPLACEMENTS 



directly with the degree of displacement, and the length of the shorter 
fragment. As has been before remarked, it is almost always found in 



Fig. 30. 




Fie. 31. 



Fig. 32. 




Transverse fracture of the femur. (Gurlt.) 



Angular displacement. 



partial fractures of the shaft and sometimes cannot be entirely reduced. 
After complete fracture it may be produced by the unopposed action of 



Fig. 33. 




Toothed fracture of the tibia. (Malgaigne.) 

the force of gravity upon the fragments or the limb, even after splints 
have been applied, or by the unbalanced contraction of certain muscles 
or groups of muscles. As a general rule, it can be corrected by perma- 
nent extension or lateral support, except when one of the fragments is so 
small or so deeply placed that it cannot be properly acted on by the 
apparatus. 



DISPLACEMENTS 



69 



3. In rotatory displacement one fragment, usually the lower, turns 
about its long axis, while the other fragment remains in position. Thus, 



Fi*. 34. 




Fracture of the clavicle. Union with extreme displacement. 
Fig. 35. 




for example, after fracture of the upper portion of the Fig. 36. 

tibia the foot and lower fragment may rotate outwards, 
while the knee remains in position, or, more rarely, as 
was pointed out by Gosselin, 1 the converse may occur, 
and the thigh rotate outwards, while the foot and lower 
fragment are held in position by the splints. This form 
of displacement is most frequently seen after fracture 
near the upper articular end of a long bone, when the 
unsupported weight of the limb tends to rotate it about 
its long axis, and it is, in fact, one of the diagnostic symp- 
toms of fracture at the neck of the femur. 

4. Overriding (fig. 37) is most common after oblique 
fracture of the shaft, and is produced by various causes, 
such as the continuation for a moment after the fracture 
of the force that has produced it, as in a fall upon the 
feet, the tonicity of the muscles, or the sliding down- 
wards of the body in the bed when the limb is fixed by 
a splint. It is to be recognized by the shortening which 
it causes, and is frequently associated with angular dis- 
placement (fig. 30). The most extreme examples are 
found after fracture near the end of a bone, where the 
shaft has split the epiphysis and passed between its 
fragments (fig. 38). 

5. Displacement by penetration or crushing has been 
already mentioned as the impacted variety of multiple fractures (p. 57). 
In short bones, that is, in those composed entirely of spongy tissue without 
a medullary canal, there is coincident crushing of both fragments at the 
seat of the fracture by which an actual loss of tissue is produced and the 
bone is shortened and bent (fig. 39). In the long bones it occurs only 
at the expanded, spongy ends, and is produced by the penetration of the 



Rotatory displace- 
ment after frac- 
ture of the neck 
of the femur. 



1 Clinique Chirurgicale, vol. i. p. 270. 



70 



DISPLACEMENTS. 



firmer and narrower fragments into the other, which is broader and more 
gy in structure. This penetration is made possible either by the 



SDOll 



Fig. 37. 



Fig. 38. 




Fracture of both bones of the leg, with overriding. 



Comminuted fracture of the 
femur, with splitting of the con- 
dyles. 



splitting of the penetrated fragment or by the crushing of its spongy 
tissue, as in the short bones. The accompanying figures represent these 



Fig. 




Fracture of the calcaneum, with crushing. 



two varieties. Usually it is the diaphysis which penetrates the epiphysis 
(fig. 40), but in fracture of the neck of the femur the latter usually 
penetrates the great trochanter (fig. 41), in accordance with the rule 
that the smaller, narrower fragment penetrates the broader one. Pene- 
tration without splitting occurs only when the spongy tissue has under- 



DISPLACEMENTS. 



71 



gone the senile atrophy or change characterized by enlargement of its 
meshes and thinning of its trabeculse. The penetration rarely takes 



Fi<r. 40. 



Fie. 41. 





Intra-avticular fracture of the head of 
the tibia, with impaction and separation 
of the upper fragments. 



Fracture of the neck of the femur, with 
crushing of the spongy tissue. Vertical 
section. 



place without a change in the direction of the axes of the fragments ; 
the resistance in the penetrated portion is greater on one side than 



Flo-. 42. 



43. 



44. 






Fracture of the neck of the humerus 
with impaction. (Malgaigne.) 



Fracture of the lower 
end of the radius. Angu- 
lar displacement of the 
lower fragment backward 
with impaction. (R. W. 
Smith.) 





Fracture of the fibula. 
Longitudinal separation. 



72 



DISPLACEMENTS. 



on the other, or the cortical shell of the penetrating one is thicker 
and firmer at one portion of its circumference than at another, so that 
the depth of the penetration varies and an angular displacement results ; 
or the same effect is produced when the direction of the fracturing force 
is not parallel to the long axis of the bone, as in some fractures of the 
lower end of the radius (figs. 42, 43). 

The exuberant callus found after consolidation of the fracture gives 
the appearance of a much deeper penetration than has actually taken 
place ; thus, in figure 43 the triangular mass of spongy tissue on one 
side of the shaft is not the penetrated epiphysis, as it seems to be, but 
is composed in part of callus that has formed above the line of fracture. 

When the impaction is in the general direction of the long axis of the 
bone, as at the upper end of the humerus or the lower end of the radius, 
the limb is shortened ; but when it is nearly at right angles, as at the 
neck of the femur, shortening may be absent or not appreciable ; crepi- 
tation and abnormal mobility are also usually lacking. 

6. Direct longitudinal separation is seen most frequently after frac- 
ture of the patella or of an apophysis to which a powerful muscle is 
attached, such as the olecranon or the coronoid process of the ulna. It 
is also seen after fracture of either malleolus when the foot has been 
dislocated towards the opposite side and has carried the fragment of the 
tibia or fibula with it (fig. 44). Gurlt 1 speaks also of the occasional 
production of this displacement after fracture of the shaft of the humerus 



Fis. 45. 




Fig. 46. 



Bony union of the patella. (Bryant.) 



by the unsupported weight of the forearm and lower frag- 
ment overcoming the contraction of the muscles which 
usually draw the fragments closer together with over- 
riding. 

This displacement is by far most frequent after trans- 
verse fracture of the patella, and is due there to the re- 
traction of the powerful quadriceps femoris which draws 
the upper fragment upward, sometimes to a distance of 
several inches. It can usually be .recognized without 
difficulty by palpation, which shows the existence of a 
groove or sulcus of varying width between the frag- 
ments. Figures 45 and 46 represent two fractures of 



'••m-f 



1 Loc. cit., vol. i. p. 108. 



DISPLACEMENTS 



73 



the patella in one of which bony union had taken place with moderate 
separation, and in the other fibrous union with wide separation. 

Among the irregular displacements, those which do not fall entirely 
within the above classification, may be mentioned rotation of one frag- 
ment about its transverse axis, as seen in some fractures of the neck 
of the humerus ; in extreme cases this rotation may bring the articu- 
lar surface into contact with the upper end of the lower fragment. 
Another is the crossing of the fragments in the form of an X (figs. 47 and 
48) ; a third is the interposition of a bone between two fractured ones, 
as in fig. 49, where the astragalus is represented as having been forced 



Fig. 48. 




^^ 



Fracture of the neck of the femur. 



Fracture of the clavicle. 



up between the tibia and fibula ; and a 
fourth includes many comminuted fractures, 
especially such as the common extra-cap- 
sular fracture of the neck of the femur with 
splitting of the great trochanter (fig. 50), 
in the separation of the condyles of the 
same bone (fig. 38). 

The character and degree of the displace- 
ment in any given case depend to a certain 
extent upon the direction and nature of the 
fracture. Thus, in a partial fracture the 
only displacement possible is an angular 
one, and in a dentate transverse fracture lateral displacement and over- 
riding are usually prevented by the interlocking of the bony points, 
while on the other hand, an oblique fracture greatly favors the simul- 
taneous occurrence of all these forms. 

The active causes of displacement are of two kinds : forces external 
to the body, and muscular action, voluntary or involuntary. The first 
comprises the immediate action of the fracturing force and the prolonged 
action of gravity upon either fragment or the entire limb during the 
period of repair. Usually these displacements may be overcome, .and 
their recurrence prevented, whenever the fragments are sufficiently large 
to be controlled by suitable splints, and when there is not much commi- 
nution or crushing. The displacements in impacted fractures and in 
most compound ones where the end of the bone projects through the 
skin, are produced at the moment of the fracture by the fracturing force, 
while most rotatory and many angular displacements are due to the 
gradual sagging of the limb or of a fragment. One of the most common 
examples is the outward rotation of the foot after fracture of the neck of 
the femur. 



<4 DISPLACEMENTS. 

Voluntary muscular action is a cause of displacement, either at the 
moment when the fracture is received and the patient is in ignorance of 
the character of the injury, or subsequently, when he is delirious or 
insubordinate. Involuntary muscular action is a cause that is always 
ready to take advantage of an opportunity and produce overriding or 



Fig. 49. 



Fig. 50. 





Fracture of tibia and fibula, with penetration of 
the astragalus between the fragments. 




Comminuted fracture of the neck of the femur. 



angular displacement. The pain of the fracture, and the irritation of the 
soft parts by the broken ends of the bones stimulate the muscles to 
steady permanent contraction, or excite twitchings and spasms which 
aggravate the pain and deformity. The traction of these muscles upon 
fragments which have lost their natural support either changes the re- 
lations of their axes or draws them past each other and shortens the limb. 
It is impossible to predict the direction and extent of the displace- 
ment by consideration of the muscles attached to the fragments. Too 
many other factors are involved, and experience has shown that fractures 
at any point may present displacements differing essentially from each 
other in different cases. At the same time, the effects of the contrac- 
tility of the muscles are not entirely casual and irregular ; the tendency 
to shortening of the limb by the combined action of all its muscles 
always exists in every case not complicated by paralysis, as does also a 
similar tendency to exaggeration of certain displacements produced by 
the fracturing cause and accompanied by free rupture of the periosteum 
and other soft parts. Malgaigne mentions a case of fracture of the neck 
of the humerus, in which the upper fragment was drawn into a position of 
extreme abduction by the supra-spinatus muscle after the lower fragment 
had been displaced far into the axilla. Lacroix 1 showed that, as a 

1 Annales de la Chirurgie Fran9ai.se et etrangere, 1844, vol. x. p. 257; quoted by 
Grurlt. 



DISPLACEMENTS. 75 

general, although not universal, rule, the displacements of the bones of 
the extremities formed angles which corresponded to the normal curves 
of these bones, which latter correspond in turn to, and are apparently 
due to the action of, certain groups of muscles. The influence of the 
muscles in most displacements by direct longitudinal separation, as after 
fracture of the patella, is, of course, beyond dispute. 



76 ETIOLOGY OF FRACTURES. 



CHAPTER IV. 

ETIOLOGY OF FRACTURES. 

The causes of fracture may be grouped under two heads : A. The 
predisposing causes, and B. The immediate or determining causes. 

A. The predisposing causes are also of two kinds: the normal or 
physiological, and the pathological. 

The normal or physiological causes are those which have their origin 
in the form, texture, and functions of the different bones, modified as 
they are by the changes incident to the advancing age of the individual. 
The statistics given at the beginning of this volume show how much more 
frequently the long bones are broken than the short ones ; and the rea- 
sons for this difference are not obscure. The liability of a bone to frac- 
ture depends upon its power of resistance, its exposure to violence, and 
the opportunity which it furnishes for the more or less advantageous 
action of this violence. The shaft of a long bone is composed of a hollow 
cylinder of very firm texture, an arrangement that gives the maximum 
of resistance against lateral flexion and breakage with the minimum of 
weight. Its principal exposure is to indirect violence, to flexion or tor- 
sion, which although applied through the ends of the bone, exerts its 
greatest fracturing force upon the shaft, as a stick is broken by bend- 
ing it. 

The short bones and the expanded extremities of the long ones have 
a different structure corresponding to their different functions and expo- 
sure. The violence which they receive is direct, their surfaces of contact 
therefore are large, and their texture uniform so as to provide for a ready 
transmission and division of the impinging force. Their shortness, both 
actual and relative, as compared with their thickness, protects them almost 
entirely from the action of indirect violence, and their relation to the 
shafts of the long bones is such that the direct violence which they re- 
ceive is transmitted into indirect violence exerted upon the latter. Thus 
in a fall from a height upon the feet the force is received upon the 
sole of the foot ; if the limbs and back are straight and rigid, it is 
transmitted directly through them and causes fracture by direct impact 
either at the ankle, or at the base of the skull, or at an intermediate 
point, but if the legs are bent and the muscles tense, the bones of 
the leg and thigh constitute, practically, a single curved bone with 
its maximum of curvature near the centre just above the knee, and 
that then becomes the point at which the fracturing strain is greatest. 
Figure 51 represents the relations of the bones of the leg and thigh 
when the knee is flexed, and the dotted lines show the direction in which 
the force is transmitted. The fracturing effort is greatest at the point 



ETIOLOGY OF FRACTURES, 



77 



where these lines cross, the point of maximum convexity in the lower 
third of the femur, and an additional demonstration of its character is 
found in the frequent projection of the lower end of the upper fragment 
through the skin of the anterior aspect of the thigh. The lateral and 
crucial ligaments, the tendon of the quadriceps femoris in front, and 



Fig. 51. 



52, 





attachments of the gastrocnemii behind, fix the condyles of the femur 
and the head of the tibia so firmly together that they form practically 
a continuous bone, and, as all experience shows, fracture above or below 
the joint is very much more frequent than dislocation. So far as fracture 
is concerned, therefore, the two bones are the same as a single bone 
having the shape represented in fig. 52. In like manner a fall upon the 
palm of the hand may fracture the humerus in its lower third. 

We find in the normal curves of the bones an indication of the means 
by which nature seeks to protect the skeleton from the effects of direct 
violence and which find their fullest development in flexion of the limbs 
and rigidity of the muscles. Every effort is made to distribute the vio- 
lence and to take it up by the elasticity of the different segments, in a 
word, to make it indirect instead of direct, to avoid shock even at the 
risk of fracture. The instinct which leads a falling man to stiffen his 
muscles is calculated to protect his viscera at the expense of his limbs. 
The proverbial immunity against fracture possessed by drunkards is cor- 
roborative of this view. 1 The additional factor of a direct strain upon 

1 Two cases were recently brought into my wards at Bellevue Hospital which, illus- 
trate this fact strikingly. One had fallen while intoxicated, from a fourth-story win- 
dow, and sustained no injury except contusions ; the other had fallen while asleep 



78 ETIOLOGY OF FRACTURES. 

the bone, by the contraction of the attached muscles will be discussed 
when we come to consider the direct influence of muscular action in the 
production of fractures. 

The position and functions of the extremities, especially the forearm 
and leg, also expose them to fracture to a degree far exceeding that of 
the bones of the trunk ; they are, as it were, outlying members, which 
are the first to receive the shock in a fall, they are often interposed to 
protect the head or body, they come into close relations with machinery, 
and are more frequently caught by falling bodies or moving wagons. 

The greater relative frequency of fracture in people over fifty-five or 
sixty years of age has been already mentioned. The cause was long 
supposed to lie in the presence of lime-salts in the bones of old people in 
larger proportion than in those of the young, but more recent investiga- 
tions have shown that the assumption upon which this explanation is 
based is incorrect. The proportions of organic and inorganic matter in 
the bone tissue itself do not change as supposed, and the real cause of 
the greater brittleness in advanced life is the actual diminution which 
then takes place in the amount of the bone substance. The external 
dimensions remain unchanged, but all the cavities increase in size by 
absorption of their walls, and become filled with fat so that the bone will 
almost float in water. The cylindrical shell of the shaft is so thinned 
in extreme cases that a very slight force is sufficient to break it, and the 
spongy tissue is similarly weakened by the disappearance of many of its 
trabecule, and the consequent enlargement of its meshes. This change 
is known as senile or interstitial atrophy, and is always present to a 
greater or less degree in advanced life. It is this weakening, this in- 
ability to withstand direct violence, that explains the especial frequency 
of certain fractures — notably those of the neck of the femur and impac- 
tion at the upper end of the humerus, or at the lower end of the radius. 
A stumble or misstep is often sufficient to fracture the neck of the femur 
in an old person, as is also a slight fall upon the knee or the great 
trochanter. 

In young children, whose epiphyses are almost entirely cartilaginous, 
the elasticity of this tissue is thought by Gurlt to be a protection against 
fracture of the shaft by indirect violence, but fractures are by no means 
so rare among them as to require such a purely hypothetical explanation 
of their rarity. They present the usual varieties of fracture, with a 
relative predominance of the incomplete or partial ones, and, as a rule, 
with much less displacement than is found in later life. This last fact 
is to be explained, in part at least, by the greater thickness of the 
periosteum. 

While atrophy is usually so moderate in degree and so widespread in 
its distribution, when it presents itself as a senile change, that it may be 
considered with propriety among the normal or physiological predispo- 
sitions to fracture, yet when it appears prematurely, or reaches an ex- 

from the roof of a four-story house and received a severe injury of the hack and a 
contusion of the foot, but had broken no bones except possibly one of the vertebrae. 
The former recovered promptly, the latter died of septicaemia originating in gan- 
grenous emphysema of the bruised foot, a dissection of which showed the absence of 
fracture. 



ETIOLOGY OF FRACTURES. 79 

treme degree, it is the result of something more than the usual senile 
wasting, and must be classed as pathological, together with other 
atrophies which show similar gross pathological changes, but whose 
nature and causes are far from being thoroughly understood. In the 
same connection may be mentioned cases of inherited congenital and 
developed liability to fracture, in which, as direct examination of the 
bones was not made, there is no knowledge of the accompanying 
anatomical conditions. Of the inherited liability Gurlt gives three ex- 
amples, extending in one case o\ r er four generations, in the others over 
three each. The following is a condensed report of one case : 1 — 

First Generation. — A woman had suffered five fractures of the left 
and one of the right thigh, caused by slight violence, and preceded in 
the last case by severe pain in the limb. Pier brother broke one thigh 
twice, the other nine times, the arm twice, and dislocated his hip once — 
all before he was thirteen years old. 

Second .Generation.— The son of the woman had fourteen fractures 
before he reached the same age (thirteen years). The first was a frac- 
ture of the femur caused by a fall from a step six inches high, and united 
in five weeks ; four months later the forearm was broken by a fall from 
a chair ; after another four months, fracture of the ulna by a wrench of 
the arm, united in three weeks ; again, four months later, fracture of 
the humerus, radius, and tibia on the right side, by a fall down two steps, 
about eleven inches ; all united in less than four weeks. Afterwards six 
fractures of different bones. 

He gives also three cases of a congenital but not inherited disposition 
to frequent fracture in the children of a family. In the first case three 
brothers were affected. The eldest suffered only one fracture, that of 
his right thigh, when he was three years old; the second brother had 
four, and the third had nine fractures between their second and nine- 
teenth years. With two exceptions the fractures were caused by 
moderate external violence ; they all united in four or five weeks, and 
caused deformity in only two cases. The liability disappeared as the 
patients advanced in years. 

In the second reported case a healthy but rather delicate girl suffered 
thirty-one fractures between the ages of three and fourteen years ; the 
right thigh seven times, the left once ; the right leg nine times, the left 
once ; the right arm four times, the left three times ; and the left fore- 
arm once. They all united rapidly and easily. Her sister, six years 
old, had suffered nine fractures, the first at the age of eight months. No 
similar predisposition existed in the parents, nor in the two brothers and 
a third sister. 

Gurlt admits his inability to find a sufficient explanation of the dispo- 
sition manifested in these cases, for neither parents nor children presented 
any recognizable cachexia or defective structure of the bones ; he places 
it, therefore, with that other obscure tendency, the hemorrhagic diathesis, 
among the problems whose solution requires many more detailed obser- 
vations. 

1 Gibson, Institutes and Practice of Surgery, 7th ed., 1845, vol. i. p. 237; quoted 
by Gurlt. 



80 ETIOLOGY OF FRACTURES. 

The cases in which individuals have developed in early 'or middle life a 
noticeable fragility of the bones without known cause are not very rare. 
Gurlt has collected seventeen such, characterized not only by the re- 
markable facility with which the fractures were produced, but also by an 
exceptionally rapid and easy recovery. He is unwilling to believe that 
in them, or in the preceding cases, the fragility was due to atrophy of 
the bone, because the majority of the individuals were reasonably well 
and strong, and did not show signs of that atrophy of the soft parts which 
has always accompanied atrophy of bone in cases where the latter con- 
dition has been verified by examination. 

The pathological condition known as general atrophy or rarefaction of 
the bone, or osteoporosis, and which has been referred 'to as senile 
atrophy, may appear prematurely, or may have its origin in other causes 
than senility — such as paralysis, locomotor ataxy, or osteomalacia. It 
is worthy of note, that in not a small proportion of the cases (excluding 
the ordinary fractures of the neck of the femur) union takes place easily 
and rather promptly. In most of the cases that furnish autopsies the 
bones are found softened and reduced to a shell by absorption from the 
inside, and in some of the cases suppuration has taken place at the frac- 
ture, and death has followed with symptoms of purulent absorption. 
The following cases, quoted from Gurlt, represent the different varieties. 

A woman, seventy-two years old, had both thighs broken by kneeling 
in church, and the humerus by the efforts of the bystanders to lift her 
up. Another broke her collar-bone by putting her arm about the nurse's 
neck, and trying to turn herself in bed. 

A weakly boy, with healthy parents, brothers, and sisters, began at 
eight months to suffer with boils (or cold abscesses) followed by exten- 
sive ulcerations, probably lupus, at the nose and ears. He had then six 
different fractures, which suppurated and caused his death at the age of 
2J years. The fractures involved the humerus, femur, both bones of 
the leg and forearm, and had not united. The bones were small, unu- 
sually spongy near the fractures, and could be easily cut with a knife, 
but were hard and rigid. The viscera were healthy. 

A woman, forty-five years old, the mother of two children, suffered a 
great deal of pain in her bones after the birth of the second child, and 
became so helpless that she could not get into or out of bed without aid. 
She broke both thighs below T the trochanters by stumbling against the 
bed-post in one case, and by turning in bed in the other. Both united 
with marked angular displacement, and at the autopsy the bones of the 
thigh and pelvis were found to be so light that they floated in water and 
could be crushed by pressure with the finger. The cortical substance of 
the femur was as thin as an egg-shell, the medullary canal enlarged, 
traversed here and there by delicate plates of bone, and filled with a 
grumous, semi-fluid mixture of blood and marrow. 

A woman, twenty five years old, began to suffer pain in all her limbs, 
especially the thighs, became bedridden, and died four days after she 
had broken her left thigh by turning in bed. The bones were of normal 
size, lighter than usual, and could be easily broken, with comminution 
and escape of much blood. The periosteum was loosely adherent, the 
bones dark red and full of blood ; the cortical layer of the femur was 



ETIOLOGY OF FRACTURES. 81 

only one line in thickness, and the canal was filled with a thick, dark 
red marrow. The neck of each femur was completely absorbed. 

A man, fifty-six years old, bedridden for many years, had both thighs 
broken while being turned in bed. Firm union followed. After death 
the bones were found atrophied and softened. 

Saviard saw in 1690 at the Hotel Dieu, in Paris, a woman about thirty 
years old who had suffered for four months with severe pains throughout 
the body, increased by movements and without fever. Three months 
later she had become bedridden, and her bones had grown so friable that 
most of them were broken, and she could not be moved without causing 
a new fracture. She lived ten months in this condition, and the autopsy 
showed fractures of almost every bone in the body. Their structure was 
so delicate that they could not be pressed between the fingers without 
breaking into small pieces ; the marrow was red, the muscles pale, the 
joints and cartilages unchanged. 

A waman, fifty-nine years old, with complaint of wandering pains, 
oedema, albuminous urine, fibrinous casts. Pains in the spinal column 
with gradual curvature ; pain in the first and second sterno- costal joints 
with swelling; fracture of the right clavicle near the sternal end without 
known cause ; lime salts abundant in the urine ; union of the fracture 
in twenty-three days. Three months afterwards, while turning in bed, 
fracture of the left clavicle at the corresponding point ; two days later 
fracture of the right femur three inches above the condyles by sitting up 
in bed and allowing the legs to hang over the side. Death six days 
afterwards. All the bones showed atrophy of the cortical layer and 
enlargement of the meshes of the spongy portion ; complete firm union 
of the left (?) clavicle (fig. 53) ; the ribs all bent and showing twelve 

Fi£. 53. 




United fracture of the clavicle. Osteomalacia. 

to fourteen fractures united with exuberant callus, but so friable that 
they could be broken by pressure between two fingers ; the vertebrae 
were as soft as gelatine, the pelvis normal in shape. 

Benjamin Bell 1 reports a case where only one bone was affected, and 
in which the pathological changes were different. He gives no intimation 
of the cause. "A gentleman at the middle period of life who fractured 
his humerus in unscrewing a music-stool. The fracture was comminuted 
and did not unite. Several months afterwards the arm was amputated 
by my father, Mr. George Bell, at the shoulder-joint. On examining 
the limb the muscles surrounding the fractured bone were found to be 
in a pulpy state, A quantity of partly fluid and partly coagulated blood 

1 Diseases of the Bones, 1828, p. 72. 



82 ETIOLOGY OF FRACTURES. 

enveloped the bone, which was fractured near its centre. Several frag- 
ments of bone, varying from one to three inches in length, lay imbedded 
in the blood. No attempt at the adhesive or reparative inflammation 
seemed to have been made. The bone was almost friable, and its outer 
surface, from the neck of the humerus to the condyles, was perforated 
by innumerable small, irregular-shaped holes, giving to the bone, when 
macerated, a true reticulated appearance ; and this peculiar reticulated 
appearance was also observable in the osseous plates of the cancelli." 

In the following case, that came under my care in 1880, the bone 
appears to have been weakened by a blow and a wound of the soft parts 
received about five weeks before. The patient was a healthy man, thirty- 
five years old, who was admitted to the Presbyterian Hospital with a 
lacerated wound across the front of the middle third of the left leg, 
caused by the fall of a stone. The wound healed in three weeks and 
he left the hospital. A fortnight later, Nov. 4, 1880, he returned with 
a compound fracture at the scar, caused by stepping down from a win- 
dow-sill to the ground, a distance of two feet. He had had no pain in 
the leg previously. The bone could be seen plainly and was rarefied 
and soft ; the fracture seemed to be transverse, and with but slight dis- 
placement. Recovery followed promptty . 

A similar friability is also found in some cases of old unreduced dis- 
location, due, it is supposed, to lack of use. This fact should always 
be borne in mind when an attempt is made to correct such a condition. 
Malgaigne thinks the danger of fracture exists only when the bone has 
been the seat of dull pain, and attributes it to a local inflammation ; but 
this opinion is hardly in harmony with all the reported facts. Prof. 
Markoe 1 reports a case of dislocation of the hip of seven weeks' standing, 
in which he fractured the femur while attempting reduction without 
apparatus and employing only a " slight amount of force." He repeats 
the same warning that the greatest care must be taken " in using bones 
which have long been disused, as levers in reducing displacements." 

Disease of the Nerve-centres. — In 1842 Davey called attention to the 
facility with which fracture sometimes occurred in lunatics, especially in 
those who were also paralytic, and the observation has been abundantly 
confirmed, Burns (vide infra) having collected more than sixty reported 
cases. Weir Mitchell 2 was the first to call attention to the frequency of 
fracture in those affected with locomotor ataxy, and suggested that the 
cause might lie in an impairment of the nutrition, and consequently of 
the strength, of the bone dependent upon the disease of the cord. 
Shortly afterwards Charcot 3 published a remarkable case of multiple 
" spontaneous" fractures and dislocations in an ataxic woman, and very 
recently Burns 4 has published a paper upon the subject based upon thirty 
cases reported within a few years. He finds that the fractures are 
usually multiple, from two to six in number, and are most common in the 
lower extremity, especially in the femur; the frequency is equal in the 
different bones of the upper extremity — clavicle, humerus, and forearm. 

1 Diseases of the Bones, p. 18. 

2 Am. Journal Med. Sci., July. 1873, p. 113. 

3 Archives de Phvsiologie, 1874, p. 166. 

4 Berliner Klin. Woclienschrift, 1882, p. 164. 



ETIOLOGY OF FRACTURES. 83 

Repair takes place in the usual time or in less, and the callus is some- 
times exuberant. 

The accident seems to occur more frequently in the earlier than in the 
later stages of the nervous disease, and its predisposing cause is a rare- 
faction of the bone marked by great absorption of the compact tissue, 
increase of fat, and loss of inorganic matter. It is not improbable that 
in some of the cases reported by the older writers and quoted above, 
especially in those in which pain is mentioned as a preliminary symptom, 
the patients were ataxic. 

Rachitis. — Friability due to rachitis is found only in childhood, for 
the disease is one which involves the bones only during their period of 
growth, and consists essentially in the prolongation and exaggeration of 
the embryonal or developmental condition of the shaft. The layer of 
tissue known as chondroid (Broca), or spongoid (Gue'rin), by means of 
which a bone grows in length, and which is intermediate between the 
shaft and the epiphysis of a growing bone, and is normally only a line 
or two in thickness, becomes in a rachitic bone very much thicker and 
continuous with a thick subperiosteal layer of similar tissue covering the 
entire shaft. The cylindrical shell of the shaft presents, instead of a 
solid, uniform, bony wall, a series of alternating layers of fully formed 
bone and the above-mentioned spongoid tissue, or there may be a thin 
compact shell adjoining the medullary canal and covered externally by 
a thick layer of this softer, incomplete, or embryonal bone. The disease 
is common among children of the poorer class, and those affected by it 
furnish, according to Guersant, about one-third of all fractures at that age. 

The spongoid tissue is composed of modified cartilage infiltrated with 
an abundance of lime-salts, and containing only a little real bone ar- 
ranged in irregular lamellae or patches ; it is more soft and friable than 
normal bone, more easily crushed or broken, and the most frequent form 
is the partial or incomplete fracture, impaction, with the fracture on the 
concave size of the bend. As the age of the individual increases, the 
bones acquire the normal structure, and their solidity is then as great as 
or even greater than it is under ordinary circumstances, because of their 
increased thickness. There is no lack of examples of rachitic fractures in 
foreign records, but the affection seems to be much rarer here. Mal- 
gaigne saw a rachitic child that had suffered four fractures (one of the 
humerus, three of the femur), between the ages of six and ten years, and 
quotes another from Jacquemille of six fractures (arms and thighs) between 
the ages of twelve and thirty-two years. In this latter patient apparently 
the rachitis had persisted much longer than usual. In the Dupuytren Mu- 
seum at Paris is the skeleton of a rachitic child, six or seven years old, 
showing twelve fractures. Lonsdale has reported one with twenty-two 
fractures, and in the London Medical Gazette (1833) is the account of 
another with thirty-one. Esquirol's famous case, mentioned in most 
works upon fractures, was a rachitic woman whose skeleton showed 
more than two hundred fractures, all more or less well united. 1 

Union takes place rather more slowly than in normal bone, and some- 
times fails entirely. The callus is usually large, but as it is composed 

1 Malgaigne. Fractures et Luxations, vol. i. p. 20. 



84 



ETHOLOGY OF FRACTUKES 




United fracture of rachitic 
femur. (Gurlt.) 



54 - of the same soft embryonal tissue whose excess is 

the pathological feature of the disease it is lacking 
in firmness. Fig. 54 shows how the medullary 
canal may be obliterated even in incomplete frac- 
ture, by the bending in of one of its sides, and also 
how the callus tends to straighten the outline of the 
bone by filling up the hollow of the angular dis- 
placement. 

Syphilis, Mercurialism, and "Rheumatism." — 
Syphilis affects the organism in so many and so 
varied forms, and causes such serious bone lesions 
in its later stages, that it is not strange that both 
physicians and patients have been inclined to attri- 
bute to it fractures produced by slight causes when- 
ever the patient was or had been affected by it. 
And in like manner those who saw in mercury the 
cause of the bone lesions of syphilis attributed the 
fractures to the use of that drug. 

When we remember what multitudes of people 
have contracted syphilis, how numerous those in 
whom it has caused grave lesions of the bones, and 
on the other hand how few are the cases in which 
it can even be suspected as a predisposing cause of 
fracture, it is evident that it has but little, if any, 
influence in this direction ; and an examination of the alleged cases shows 
very frequently a coexistent constitutional weakness or a cachexia not 
always to be attributed to the specific disease, which creates a close re- 
semblance between these cases and those in which the friability of the 
bone is due to a premature or exaggerated senile atrophy. The patho- 
logical anatomy of syphilis, too, does not show any morbid change pro- 
duced in bones by this disease which would markedly increase their 
friability, although there are some specimens of hyperostosis, of general 
enlargement of the shaft of a long bone, accompanied by such a rarefac- 
tion of the tissue that the strength of the bone is lessened, notwithstand- 
ing its enlargement. 1 have one such specimen in which the lower third 
of the femur is nearly doubled in diameter, while its wall is much thinned 
and abnormally porous. It is of course possible that this rarefaction 
may exist without hyperostosis or actual increase in size, and the strength 
of the bone be notably diminished thereby, but there is no proof of it, 
if we except the caries sicca of the cranial bones, a process marked by 
absorption of the bony tissue about the minute canals and under the 
periosteum, and consequent production of depressions on the surface or 
of perforations, some of which may extend entirely through the bone. 1 

In only two of the fifteen cases collected by Gurlt 2 in which fractures 
were produced by slight causes in syphilitic individuals were the bones 
examined ; in one of them after death, in the other incidentally to an 
operation for pseudarthrosis. Of the former it is stated only that the 



1 Compare Keyes, Venereal Diseases, 1880, p. 

2 Loc cit., p. 179. 



186. 



ETIOLOGY OF FRACTURES. 85 

bones were very friable ; of the latter it is said the pieces removed were 
soft and friable, and the medullary canal enlarged with notable thinning 
of its wall and a great excess of fat. In one case the humerus was 
broken two or three times and the clavicle twice, in the other the femur 
once by slight causes ; both patients were of delicate constitution, and 
one of them died,' apparently of phthisis, at the age of 27. They can- 
not be said to prove anything in this connection. 

It seems not improbable, on general grounds, that syphilitic pain in 
the bones may be the result of pressure within the Haversian canals or 
under the periosteum, and that this pressure if not relieved may result, 
as it does under other circumstances, in an enlargement of the affected 
canals by absorption of their walls, in other w T ords, in rarefaction of the 
bone and consequent diminution of its strength, just as in general atro- 
phy. Gurlt's fifteen cases include five in which the fracture was pre- 
ceded by severe pain, more or less prolonged, in the broken bone, and 
these might be considered as demonstrative of the influence of syphilis 
did we not possess other similar cases in which the syphilitic complica- 
tion does not exist. Malgaigne, 1 indeed, speaks of local inflammation of 
the bone as a frequent and too much neglected predisposing cause of 
fracture, adding : "I give this name, conjecturally, to an affection which 
generally manifests itself by dull pains attributed by the patient to some 
contusion or to rheumatism, rarely sufficient to cause a general reaction, 
and attracting but little attention until some slight cause produces frac- 
ture at the point it occupies." There is a striking similarity between 
the cases he cites in this direction and Gurlt's syphilitic cases. 

"Rheumatic" Cases. — A carpenter's apprentice suffered for a month 
with rather severe rheumatic pains in the left arm, and then broke it by 
pressing firmly upon the handle of a centre-bit, which he was turning 
with his right hand. 

A laborer broke his right arm by throwing a stone. He had always 
been healthy, but during the preceding month he had been suffering 
from pain in this arm which had increased to such a degree that he had 
stopped work. 

A strong well-built youth of 20 years broke his femur by a fall upon 
the ground while walking ; for a few weeks previous to the accident the 
limb had been the seat of pains supposed to be rheumatic. 

Syphilitic Cases. — A woman, 40 years old, had pain at night for a 
year in the middle of the arm, and then broke it at the affected point, 
without violence. On examination a perforating ulcer was found on her 
soft palate; the fracture healed in seven weeks under anti-syphilitic 
treatment, and a year later she presented herself with nodes on the left 
femur. 

A soldier suffered for a long time with nightly osteocopic pains in the 
right humerus, accompanied by fever and loss of flesh, and relieved by 
baths and mercurial inunctions. During slight salivation produced by 
the internal administration of the bichloride of mercury, and while the 
pain was still diminishing, he broke the arm in the middle by trying to 

■ Loccit., p. 22. 



00 ETIOLOGY OF FRACTURES. 

turn upon his right side. An "exostosis" was found extending from 
the elbow to the seat of fracture. Union took place within a month. 

A man of delicate constitution had a chancre and two buboes in 1814, 
followed by ulcers in the neck and pain in the bones. In 1816 he was 
treated twice in Berlin by inunctions, which reduced his strength greatly, 
but did not relieve his symptoms. His right arm, which had long been 
the seat of severe and constant pain, was then broken by slight violence, 
and the fracture did not unite. In 1818, being in a very wretched con- 
dition, he consulted Delpech, and was placed upon a tonic treatment, 
during which the fracture seemed to unite, but after a somewhat violent 
movement one day a new fracture was found two inches below the first. 
Sometime afterwards, the tonic treatment having been kept up mean- 
while, Delpech cut down upon the bone, found the upper fracture united 
by a pliable callus, and the lower one without a trace of union ; he re- 
moved at different times about three inches of the bone, which was soft 
and fragile, with thin walls and full of fat, and obtained fibrous union. 
Under mercurial and tonic treatment the syphilitic symptoms disappeared, 
but the left clavicle became the seat of severe pain and was broken in 
the centre by the effort made in putting on a vest ; this fracture united 
solidly, and was followed by another at the sternal end of the same bone, 
also preceded by severe pain. 

An apothecary, 1 38 years old, broke his right humerus while drawing 
a tooth. For a year previously he had suffered more or less with pain at 
the seat of the subsequent fracture, and the bone had seemed so weak 
that he feared to use it, although it had increased greatlv in thickness. 
He had also pains at night in his head and joints, and nodes upon the 
skull, and was taking the iodide of potassium. The fracture united 
promptly, but the arm remained useless. 

There seems to be no reason to suppose that mercury has any direct 
action upon the bones, rendering them more liable to fracture, and the 
most that can be claimed, is that its excessive, unskilful use will cause 
a general deterioration of the health, which may result in an atrophy of 
the bones, similar to that found in old age and in some paralytic condi- 
tions. 

Cancer. — There are two ways, apparently, in which the development 
of a cancer may lead to fracture of one or more bones : either the tumor 
may occupy the bone itself, primarily or secondarily, and destroy it to 
such an extent that the slightest force is sufficient to fracture it, or the 
presence of the tumor elsewhere may induce a cachexia which results in 
an atrophy of the bone similar to that found in the senile condition. 
The first stage of the development of a cancer in bone presents the 
changes of rarefying osteitis with substitution of granulation or fibrous 
tissue for the bone, the cancer cells then develop in this new tissue, as 
they do in fibrous tissue elsewhere. In a case of extensive generaliza- 
tion of cancer which came under my observation, portions of several 
ribs and vertebrae, a large part of the pelvis, and the upper portion of 
the right femur were so changed in texture, although their external form 

i W. Parker, in N. Y. Journ. of Med., July, 1852. 



ETIOLOGY OF FRACTURES. 



87 



Fiff. 55. 



was perfectly preserved, that a knife could be easily thrust through them. 
Under other circumstances the morbid growth seems to localize itself in 
the medullary canal, and to destroy the cortical layer by absorption ; 
when the latter is reduced to a thin shell, a very slight effort may frac- 
ture it. This occurred also in the case to which reference has just been 
made. The right femur was broken at the junction of the lower and 
middle thirds, by the patient turning in bed about a fortnight before his 
death. The external dimensions of the bone were unaltered at the seat 
of fracture, but it was reduced to a shell not more than a line in thick- 
ness, and its interior was filled by a mass of soft pink tissue, which ex- 
tended two or three inches along the medullary canal on either side of 
the fracture, widening it, and even perforating its wall in places. 

When the tumor is sufficiently large to be easily recognized from 
without, and to clearly account for the- fracture, even if not to cause it 
to be anticipated, we should look upon the fracture as an accident or 
epi-phenomenon of the tumor, rather than regard the tumor as a predis- 
posing cause of fracture ; but in the other class of cases, where the 
presence of the morbid change in the bone is not recognizable, when the 
fracture occurs without any warn- 
ing, and is the first thing that calls 
attention to the bone, or even, as 
in Louis's case, first brings to the 
surgeon's knowledge the existence 
of a cancer at another point, we 
may certainly class it with the 
other constitutional predisposi- 
tions. Gurlt 1 collected thirty-eight 
cases of this latter kind, of which 
the following may serve as ex- 
amples of the different varieties, 
modes of termination, and possi- 
bility of reunion. 

Louis 2 was called to see a nun, 
sixty years of age, whose arm had 
been broken by the efforts of a 
coachman to help her into a car- 
riage. Union did not take place, 
and six months afterwards, while 
seated in a chair, she broke her 
femur by letting her hand fall upon 
it. Louis, seeking the cause of 
this fragility, then learned, for the 
first time, that the patient had an 
ulcerated cancer of the breast. 

A woman, 3 forty years of age, 
who had a cancer of the breast 0ancer of the femur _ Fractare . (CrU veiiMero 




1 Loc. Cit., p. 184. 

2 Quoted also by Malgaigne, vol. i. p. 14. 

3 Cruveilhier's Anat. Path. Livraison XX. PI. I. fig. 4. 



88 ETIOLOGY OF FRACTURES. 

for some time, with well-marked cachexia, broke her right femur in the 
lower third by rising from a chair. She was taken to the hospital, and 
there the other femur was broken by the interne as he was preparing to 
apply a bandage to the first. She died the same night, and at the 
autopsy cancerous masses were found in the spongy tissue and in the 
medullary canal at the points of fracture and elsewhere (fig. 55), also 
in the vertebras and cranial bcnes. 

A woman, thirty-four years old, had an encephaloid tumor in the left 
axilla. She broke her left humerus with an audible snap by pressing 
against the side of the bed, and died three days afterwards. At the 
autopsy two ribs were found fractured, in addition to the humerus, and 
numerous cancerous nodules were scattered over the peritoneum, costal 
pleura, ribs, and abdominal viscera. There was no sign of any heterol- 
ogous growth in the broken humerus, and the other humerus was not 
brittle. 

A woman, 1 forty-nine years old, with tumors under the lower jaw, in 
both breasts, the uterus, and other organs, broke her right humerus 
while washing one of her children, then her left humerus while cutting a 
piece of bread, then the clavicle by throwing a book out of bed, then 
the right humerus again by rising in bed, and the left humerus again by 
tearing the burning clothing off a child. All the fractures united readily, 
with abundant callus. 

A woman, fifty-two years old, with ulcerated cancer of the breast, had 
her humerus broken by the efforts of the nurse to raise her in bed. Good 
union apparently in six weeks ; death by exhaustion in ten weeks. On 
inspection the fracture appeared to be healed, but on sawing the bone 
longitudinally, the broken ends were found unaltered in appearance in 
thickness, and inclosed in a rather thin bony ring. A mass of fibrous 
tissue, in which were imbedded numerous smaller masses, composed en- 
tirely of cancer-cells, filled the medullary canal at the seat of fracture, 
and similar small cancerous masses were found at other points of the 
canal. The cortical layer of the bone was eroded at points correspond- 
ing to the cancerous nodules, and in some places even perforated. Can- 
cerous nodules in the liver. 

A woman, forty-seven years old, broke her femur just below the 
trochanters by getting out of a wagon, fifteen months after a cancer of 
the breast had been removed by operation. Union took place in six 
weeks, and she died nine months afterwards of exhaustion. The autopsy 
showed that the upper portion of the femur had been changed into a 
large meshed network, with tenacious dirty-gray contents. The fracture 
had followed the intertrochanteric line, and the union had been accom- 
plished by interlacing spicule of bone passing from one fragment to 
the other. 

Of thirty-two of these cases in which the position of the primary 
tumor is noted, it occupied the mammary gland twenty-six times (once 
in a man); and of the entire thirty-eight cases thirty-five were women. 
As a rule, too, the affection was of long standing ; in many of the cases 
the tumor had returned after removal, and in nine it had ulcerated. 

1 Lancet, April 8, 1837. 



ETIOLOGY OF FRACTURES. 89 

The humerus and femur were almost exclusively affected, but in very 
unequal proportions — twenty-six fractures of the femur and seven of the 
humerus. Severe localized pain in the bone preceded the fracture in a 
number of cases. 

Reunion took place in one-fourth of the cases, and "in at least three of 
these there was cancerous degeneration of the bone at the seat of the 
fracture. In most of the remaining twenty-eight cases death, due to the 
progress of the disease, followed so soon after the accident that the bones 
had not time to unite, even if they were capable of carrying on the 
necessary processes. There is no reason to doubt the probability of re- 
union in cases where the recurrence of fracture has been favored by 
simple atrophy, for such reunion is the rule in other cases where similar 
atrophy has been induced by other causes ; but when the predisposing 
cause has been absorption of the bone by the growth of a cancerous mass 
within it, not only does the subsequent growth of the tumor, which is all 
the more rapid in consequence of the relief of pressure, continue the 
work of destruction, but the mass itself constitutes a mechanical obstacle 
to union by its interposition between the fragments, and, in addition, the 
destruction of the marrow and the reduction of the bone to a mere shell 
remove the two principal elements by which the process of repair is 
normally carried on. In the ossifying forms of cancer it is possible that 
trabecule starting from either end may unite with one another, and thus 
bind the fragments together, as occurred possibly in the last case men- 
tioned above. 

Hydatid and other Cysts ; Caries and Necrosis. — There are a few 
instances on record in which the unsuspected development of a hydatid 
cyst within a bone has resulted in its fracture by slight violence at the 
point occupied by the cyst ; and others in which a similar result has 
been produced by the occurrence of a cystic degeneration of unspecified 
character within the bone. These causes act by direct absorption of the 
cortical layer of the bone, not by a modification of its structure, and 
their effects are confined to the single bone and the single point involved 
by the disease. Facts of this kind deserve mention in this connection 
only on account of their resemblance to other cases in these respects, 
that the fracture is produced by slight violence, and no warning is given 
by change in the volume or functions of the limb. 

While caries and necrosis are among the most common of diseases, and 
often cause a very considerable loss of substance, Gurlt says the exam- 
ples of fracture during the existence of either condition are exceedingly 
rare. The reasons are apparently of two kinds : the disease is in itself 
of sufficient importance to require the affected limb to be kept more or 
less completely at rest, and thus withdrawn from exposure to the usual 
immediate causes of fracture ; and, secondly, the process is either ac- 
companied by compensatory ones which strengthen the bone by forming 
new tissue in the place of that which is destroyed, or it affects the short 
bones or the spongy ends of the long ones, which, as has been shown, 
are the least liable to be broken. When the shaft of a long bone becomes 
necrosed in whole or in part in consequence of an acute periostitis, or 
osteo-myelitis, the dead bone retains, not only its firmness, but also its 
connection with the living portions until an involucrum has been formed 



90 ETIOLOGY OF FRACTURES. 

about it, and this involucrum is ordinarily sufficiently large to resist effec- 
tually any fracturing violence to which it may be accidentally exposed. 
The chronic carious process often lasts for years without causing much 
loss of substance, and the bone is strengthened by condensation, ebur- 
nation, of the parts adjoining the cavity ; but when the process is more 
rapid, and the loss of substance is greater, involving almost the entire 
thickness of the shaft, fracture is likely to be caused if the limb is not 
handled with great care. Fig. 58 represents the lower end of a femur 




B 

Fracture of carious femur. A. Epiphyseal cartilage. B. Crucial ligament. C Point of fracture. 

removed by amputation after fracture in a case which came under my 
observation in 18T7. The patient was a lad of twelve years, who had 
been affected for some time with suppurative disease in the right femur 
and tibia ; a fistulous opening above the knee led to bare bone, and an 
operation was undertaken for its removal. After the bone had been ex- 
posed, and two small necrosed fragments removed, the surgeon tried to 
straighten the partly flexed leg. without using much force, however. A 
sharp crack was heard, and it was found that the bone had been broken. 
The figure shows that the lower fragment had been so bent by the pro- 
longed flexion of the knee and the traction of the posterior muscles of 
the thigh, that its articular surface was directed rather backwards than 
downwards. 

B. Immediate or Determining Causes of Fracture. 

These exist in every case of fracture, for a bone breaks only when 
the strain to which it is subjected is superior to its power of resistance. 
It is entirely immaterial whether this strain or this power of resistance 
is great or small, and therefore the term spontaneous, which is some- 
times applied to fractures produced by very slight violence, such as turn- 
ing in bed, ought to be abandoned, for it does not properly express the 
idea which it is intended to convey. 

The immediate cause of a fracture may be either a force acting from 
outside the body, as in a blow or a fall, or one originating within the 
body, and exerted directly upon the bone which is fractured by the 



ETIOLOGY OF FRACTURES. 91 

action of muscles attached to or closely connected with it. Those pro- 
duced by the first cause are called fractures by external violence ; those 
by the latter, fractures by muscular action. 

a. Fractures by external violence. The division of these into two 
classes, of which one is called fractures by direct, the other fractures by 
indirect violence, is based upon clinical differences often of extreme im- 
portance, and not simply upon mechanical differences in the mode of 
transmission and in the effect of the applied force. This relieves us, 
therefore, from the necessity of examining into the latter questions with 
their many obscure factors and complex relations, and makes the defi- 
nitions simple. A fracture by direct violence is one, surgically speaking, 
in which the bone is broken immediately under the point upon the sur- 
face where the fracturing violence is received ; and a fracture by indi- 
rect violence is one in which the fracture takes place at a distance from 
that point. Thus, a fracture of the leg by a blow with a heavy bar, by 
the passage across it of a wheel, or by the impact of a rifle-ball, is a 
fracture by direct violence, while a fracture of the thigh by a fall upon 
the feet, or of the clavicle or humerus by a fall upon the hand, is a frac- 
ture by indirect violence. The most important clinical difference between 
the two varieties depends upon the injury to the overlying soft parts in 
the one case, and the absence of such injury in the other, upon the prob- 
ability that in the former the fracture will be compound, and will suppu- 
rate on account of the bruising and subsequent sloughing of the soft 
parts, and that in the other it will be simple, or if compound may not 
suppurate, and may run the course of a simple one. In addition, frac- 
tures by direct violence are more likely to be comminuted and to be 
accompanied by serious injury to adjoining vessels and nerves, which 
may necessitate amputation. 

It is worthy of remark that the skin is not always broken in fractures 
by direct violence, even when the vulnerant force has been extreme and 
the injury to the soft parts under the skin very extensive. The tough- 
ness and elasticity of the skin sometimes preserve it, especially when 
the body that exerts the violence acts over a large surface, and does not 
present sharp angles or edges. The passage of the wheel of a heavily 
laden wagon across the leg may crush both bones into splinters and re- 
duce the muscles to a pulp without breaking or even apparently injuring 
the skin. On the other hand, the blow may break the skin at the point 
where it is received and produce fracture by indirect violence at a greater 
or less distance, the bone yielding at its point of least resistance, and 
not at that where the force is directly exerted. 

The fracturing force may be applied directly or indirectly to the bone 
(causing compression, splitting, or penetration), or obliquely to its long 
axis, or as torsion, or as avulsion. Examples of the first are furnished 
by falls upon the feet with fracture of the calcaneum, gunshot wounds, 
impacted fracture of the lower end of the radius or of the upper end of 
the humerus with penetration of the epiphysis by the hard shell of the 
shaft, of the second by most fractures of the shafts of long bones, of the 
third by some fractures of the leg where the foot is fixed and the body 
turned forcibly about it, and by others in which the fracturing force is 
due wholly or in part to the action of muscles attached to the side of the 



92 ETIOLOGY OF FRACTURES. 

bone and exerted in a plane that is not parallel to its axis, and of the 
fourth by fracture of either malleolus by lateral displacement of the foot. 
The mechanism. in direct fractures produced by falls or by blows is the 
same, for from a mechanical point of view it is indifferent whether the 
force is developed by the movement of the limb or of the external object 
with which it comes into contact. 

Indirect fractures are by far more common in long bones than in short 
ones for reasons that have been considered already in the section on 
form and function considered as predisposing causes of fracture. The 
principle of their production, which was also mentioned in the same sec- 
tion, is that of the transmission of a force along a bone or set of bones 
made rigid by ligamentary attachments or muscular contraction in such 
manner that it is resolved into forces acting in two or more directions, 
one of which crosses the long axis of the bone and acts as if it had been 
applied directly at the point of least resistance in a lateral or transverse 
direction. The effect is modified greatly by the anatomical structure 
and form of the bone, the attitude of the limb, the contraction of the 
muscles, and the direction of the blow. Thus, a fall upon the hand may 
break the lower end of the radius, both bones of the forearm, the hume- 
rus, or the clavicle ; a fall upon the foot may fracture the calcaneum by 
direct violence, or the bones of the leg, the thigh, or even the vertebral 
column or skull by indirect violence. Pressure against the sternum may 
break the ribs by exaggerating their curves ; pressure against the wings 
of the pelvis may produce a similar result. 

The best example of the fracture of short bones by indirect violence is 
furnished by the spinal column, the bones of which, considered as a 
group, constitute a long bone with several curves, resembling the clavi- 
cle in its entirety and in the mechanism of its fractures so far as they are 
produced by exaggeration of a normal curve. 

Indirect fracture by traction upon a bone occurs exclusively at apophy- 
ses which give attachment to strong ligaments through which the force is 
conveyed. Thus, the internal malleolus is torn off by the forcible rota- 
tion outward (eversion) of the sole of the foot ; the internal lateral liga- 
ment is put upon the stretch, and if, as is usually the case, its attach- 
ment to the bone is stronger than the cohesion between the particles of 
the bone itself the latter yields and a transverse fracture results. A 
similar mechanism is sometimes found at the elbow on the inner, and pos- 
sibly also on the outer, side. 

b. Fractures by muscular action. Under this head are included only 
those fractures in which the rupturing . force is exerted by the muscles 
alone without the aid of any external violence. It is of course evident 
that if an individual breaks his skull or a limb by running or striking 
against a solid object the force that causes the fracture is developed by 
the action of his muscles, but the mechanism is the same as if he had 
fallen from a height or as if his body was at rest and the object with 
which he has come into contact was in motion. Only those cases are 
considered to be fractures by muscular action in which the action is ex- 
erted directly by the muscles upon the bones to which they are attached 
(mediately or immediately), either as direct traction, or in fracture of 
the patella or of the olecranon, or obliquely, according to the principle 



ETIOLOGY OF FRACTURES. 93 

of the lever, or by exaggerating the normal curve of the bone by drawing 
upon one of its extremities. Mention has already been made (page 74) 
of the influence exerted by the contraction of the muscles in favoring the 
production of fracture by external violence, an influence which is demon- 
strated experimentally by the extreme difficulty of producing the common 
indirect fractures in a cadaver by throwing- it from a height, and which is 
explained in part by the fact that the muscles when rigid hold contiguous 
bones together so closely and so firmly that they practically form one 
long bone more or less curved and therefore more exposed to fracture by 
over-bending, and in part by the additional strain which the muscles 
exert upon the bones. 

Some authors have expressed the opinion that no bone can be broken 
by simple muscular contraction unless it has previously undergone some 
change that has diminished its strength, but this opinion must be looked 
upon as an attempt to explain away by an unfounded, or at least un- 
proven, assumption a difficulty which does not really exist. It is un- 
questionable that in all cases of fracture by slight muscular action a pre- 
vious change in the strength of the bone must have taken place, and in 
many of them this change has been demonstrated by direct examination. 
Several such cases have been described under the different predisposing 
causes of fracture. But it is no more logical to claim that such a change 
has preceded every fracture by muscular action than it would be to 
make the same claim for fractures by external violence ; it can rest only 
upon the assumption that the power of resistance of a normal bone is 
superior to any force that a muscle or group of muscles can exert upon 
it under the most extreme and unusual circumstances, whereas, on the 
contrary, nature's precautions and adaptations are as a rule calculated 
upon the basis of the probable, not of the exceptional. Such a position 
may be taken with propriety with reference to all fractures produced by 
slight causes in the old, the weak, or the cachectic, or in those who have 
suffered pain at the point of fracture for some time previous to the acci- 
dent, but it is entirely unsupported by proof in the rarer, but still suffi- 
ciently numerous, cases of fracture of the shaft of a long bone produced 
by a violent effort in a healthy athletic man, and in the common ones of 
fracture of the patella or olecranon. 

The effect of muscular action is manifested in all the degrees of vary- 
ing importance between its relatively unimportant additions to the effects 
of external violence, and those cases in which it is the sole agent of 
the fracture of a healthy bone. The intermediate degrees are presented 
by those fractures, usually of weakened bones, in which moderate mus- 
cular action has acted either alone or combined with some external vio- 
lence. In the first case, when the power of the muscle is exerted in the 
same direction as the external violence, it increases the fracturing force 
by just so much : and, by prolonging its effect after the fracture has been 
made, it also increases the displacement of the fragments and the lace- 
ration of the soft parts. The principal interest of the intermediate cases 
is connected with the cause of the exceptional fragility of the bone, and 
as it has been previously discussed, with illustrative examples, in that 
connection, it does not require further attention here. 

The commonest examples of fracture by muscular action alone are 



94 ETIOLOGY OF FRACTURES. 

furnished by the patella and the olecranon, and similar, but rarer, exam- 
ples have also been given by other apophyses to which powerful muscles 
are attached, such as the posterior portion of the calcaneum, the coronoid 
process of the ulna, and the coracoid process of the scapula. These 
fractures are almost exactly transverse, and in most cases show that the 
resistance of the bone to direct traction is less than that of the tendons 
through which the traction is exerted. The patella is a sesamoid bone 
developed within a tendon, and is practically the weakest point in it, for 
the great majority of the cases of its fracture are, apparently, fractures 
by direct muscular action unaided by any leverage ; the bone is broken 
as a rope is, by direct traction upon it. 

Of the long bones the humerus is the one most frequently broken in 
this manner ; out of 85 cases of fracture of the limbs by muscular action 
collected by Gurlt 1 57 were fractures of the humerus, 15 of the thigh, 
8 of the leg, and 5 of the forearm. He gives also some remarkable 
cases of fracture of the sternum and of the vertebral column by unaided 
muscular action. The mechanism seems in most cases to be the same as 
in indirect fracture ; in some the fracture takes place at the point of 
insertion of the muscle, and in others the elements are too complex and 
too uncertain to be explained theoretically. In a comparatively small 
number of cases the fracture was caused by the convulsions of epilepsy 
or tetanus, and in others by reflex contractions or spasms in limbs that 
had been long paralyzed, but usually the cause was a violent voluntary 
muscular effort to avoid a fall, or to throw a stone, or lift a heavy object. 
The following cases taken from Gurlt illustrate the different fractures 
and the different methods in which they may be produced. It must be 
remembered that fractures produced during convulsions need to be closely 
examined in order not to overlook the possible addition of external vio- 
lence by a fall from the bed or by striking the limb against a solid object. 

In a negro boy, twelve to thirteen years of age, affected with tetanus, 
both thigh bones were broken " at the neck," probably just below the 
trochanter, by the contraction of the muscles, and the tragments forced 
through the skin on the outer side of the limb. An inch had to be 
removed from one of the bones before reduction could be effected. 
Recovery with angular displacement followed. 

Lente 2 reported a case of fracture of both femurs at an interval of 
eight months in a child twelve years old, during epileptic fits. The 
fractures w T ere at the junction of the upper and middle thirds of the 
bone ; the first united with considerable shortening ; the patient died six 
weeks after the occurrence of the second fracture, which had not united. 

The majority of the recorded fractures of the humerus were produced 
by the effort of throwing some object, a ball or a stone, with violence, 
and Gurlt thinks the mechanism is the same as that by which a stick is 
broken when it is grasped at one end and snapped sharply like a whip. 
The contraction of the deltoid arrests the bone suddenly and the impetus 
of the lower end of the humerus causes the break, which, however, may 
take place at either end or at the middle of the bone. 

1 Loc. cit., vol. i. p. 232. 

2 Am. Med. Times and Advertiser, July 21, 1860, quoted by Hamilton. 



ETIOLOGY OF FRACTURES. 95 

An athletic man, 1 thirty-four years old, accustomed to lift heavy 
weights, broke his humerus with an audible snap just below the insertion 
of the deltoid by the effort made, on a wager, to throw a stone weighing 
about two ounces the distance of a hundred yards. Eecovery in six 
weeks. 

An apparently robust and healthy man, 2 twenty-one years old, broke 
his humerus in the lower third by throwing an oyster shell with some 
force out upon the ice from the bank of the river. Recovery in the 
usual time. 

A powerful and healthy student 3 broke his humerus in two places in 
a duel while making the stroke known as u Quarte." 

Gurlt gives also eleven cases in which the humerus was broken during 
that trial of strength in which two men place their elbows upon a table, 
clasp hands with the forearms parallel and vertical, and strive to force 
each other's hand backwards. In almost all these cases consolidation 
took place within the usual limits of time. 

Fractures of the femur are rarer than those of the humerus. They 
may occur at any point on the shaft, and in the recorded cases have been 
the result of an attempt to kick, to avoid a fall, or to rise from the ground 
without aid, or of cramps, excited in one case by drawing on a tight boot, 
and in another by turning in bed. 

A colonel of cavalry, 4 36-38 years old, of middle size and great 
muscular power, broke his thigh at the junction of the upper and middle 
thirds by kicking at and missing his servant. 

Barnard Van Oven, 5 described before the Royal Medical and Chirur- 
gical Society, a fracture of the thigh sustained by himself. He was 56 
years old, healthy and strong, and free from taint of cancer, scrofula, 
syphilis, etc. He was awakened one night by a sharp, cramp-like pain 
above the knee, and as he felt the part with his hand and noticed that 
the muscle was tense, he heard a snap, followed by relaxation of the 
muscle, crepitation, and diminution of the pain. Examination showed a 
transverse fracture of the lemur three inches above the knee ; complete 
recovery in four months. 

A cavalry man, 6 29 years old, while trying to rise from a sitting posi- 
tion on the ground without the aid of his hands, broke his right thigh 
transversely at its middle. A diseased condition of the bone could not 
be show T n. 

Hamilton 7 reports a fracture of the shaft of the femur in a large and 
perfectly healthy man, occasioned by a twist of the leg in rolling ten- 
pins, and Gurlt mentions an unrecorded case of fracture of the thigh at 
two points, produced by a similar cause, in a not entirely healthy man 
of 35 years. 

Gurlt's eight cases of fracture of the leg comprise four of both bones, 

' Guthrie, Lond. Med. and Surg. Journal, 1835, vol. vi. p. 478. 

2 Kirkbride, Am. Journal Med. Sciences, 1835, vol. xvi. p. 33. 

3 Keil, De Fragilitate Ossiuru, etc. Vratislav, 1845, p. 23. 

4 Journal universel des Sciences Med., t. xi. p. 373. 

5 Lancet, 1852, vol. ii. p. 591. 

6 Gaz. Med. de Paris, 1842, p. 218. 

7 Fractures and Dislocations, 3d ed. p. 30. , 



96 ETIOLOGY OF FRACTURES. 

one of the tibia, and three of the fibula alone, the latter being fractures 
at the upper end of the bone by the vigorous contraction of the biceps. 

A small rather corpulent woman, 45 years old, slipped on the left foot 
while descending some steps, made a violent effort with the right leg to 
avoid a fall, felt at once a very severe pain in the latter, and fell in a 
sitting posture upon the bottom step. An immediate examination 
showed a fracture of both bones at the middle of the leg, the muscles of 
the calf strongly contracted, and a small wound of the skin over the 
anterior angle formed by the fragments. 

A woman, 1 52 years old, mistook in the dark a door leading into the 
cellar for one opening into a closet, and, recognizing the mistake as she 
put her right foot forward, drew herself instinctively backward, and felt 
at the same moment something snap in her left leg, upon which the 
weight of her body rested. She fell and rolled down the steps. On. 
examination, a fracture of the left fibula just below its head was found. 

Fracture of either or both bones of the forearm has been caused by 
the wringing of wet clothes, or by shovelling. The accident is among 
the rarest of fractures by muscular action, only five cases being reported 
by Gurlt. 

A healthy girl, 2 18 years old, while wringing clothes, felt a sudden, 
sharp pain on the inner side of the forearm above the wrist. Three 
days afterwards a fracture of the ulna 67 millimetres (2J inches) above 
the wrist was recognized by the abnormal mobility and crepitation. 
Union in a month. A year previously she had dislocated the lower end 
of the ulna backwards, which must have interfered with the movement of 
supination. 

A woman, 3 30 years old, broke the radius in its lower third with 
severe pain, while wringing two heavy towels. Recovery in 36 days. 

A healthy, powerful lunatic, 4 while using a shovel heard two distinct 
snaps in his right forearm, and found himself unable to use the limb. 
The next day Malgaigne found a fracture of the radius near its centre, 
and a fracture of the ulna about an inch nearer the wrist, w r ith consider- 
able displacement. 

Fractures of the clavicle have been caused by the effort of raising a 
heavy object, shovelling, and striking backwards, or with a whip. 

Malgaigne 5 reports two cases of fracture of the clavicle caused by an 
effort to toss a heavy body upwards ; one in the outer half of the bone 
in a man 41 years old ; the other in the inner third in a youth of 18 years. 

Gosselin 6 reports a case of fracture of the clavicle in its middle third, 
caused by the effort to raise a heavy piece of marble and place it upon 
the shoulder of a fellow workman. 

Fractures of one or more ribs are not infrequently caused by violent 
coughing. The sternum has been broken in four recorded cases by the 
violent straining and bending backwards of the body during the expul- 
sive efforts of parturition, and there are three or four cases of fracture 

1 Revue Med. Chirurg. de Paris, t. xvi. 1854. 

2 Labatt, Dublin Med. Press, 1840, and Gaz. Medicale, Paris, 1840, p. 475. 

3 Gazette des Hopitaux, 1844, p. 224. 

4 Malgaigne, Fractures and Luxations, vol. i. p. 585. 

5 Loc. cit., p. 464. 6 Clinique Chirurgicale, 1873, vol. i. p. 413. 



ETIOLOGY OF FRACTURES. 97 

of the vertebral column by muscular action alone, 1 and four of the 
scapula. 

Monteggia 2 saw a man 50 years old who had broken a rib by violent 
coughing. The crack was heard by members of the family present in 
the room. No further details. 

Hilton 3 reports the case of a man who broke a rib by muscular action 
while trying to mount a spirited horse. He was treated for a long time 
for pleurisy before the fracture was recognized. 

A primipara, 4 24 years old, taken in labor sought to hasten delivery 
by forcible voluntary expulsive efforts, bending backwards and resting 
on her elbows and heels. During this effort she felt a sudden sharp 
pain and a snap in the middle of the breast, and said at once that some- 
thing had broken there. No attention was paid to the statement until 
five days afterwards when, peritonitis having appeared, an examination 
w T as made and a painful swelling found in the upper portion of the ster- 
num, with quick and difficult respiration and increased pulsation in the 
large vessels. The patient died on the 17th day, and at the autopsy a 
transverse fracture of the sternum was found 1J lines above the junction 
of the body and the manubrium. The edges of the fracture were separ- 
ated, and an inflammatory exudation as large as a hen's egg and con- 
taining pus was found in the anterior mediastinum. 

A soldier 5 bathing in the Sambre dived into the river, and, not reap- 
pearing, was sought for and brought out. His body showed no trace of 
external violence, but there was paralysis of all the limbs, loss of sensa- 
tion, inability to hold up the head, pain at the posterior and lower part 
of the neck, priapism, frequent desire to urinate. He said that as he 
dived he saw the water was too shallow, and in the effort to avoid strik- 
ing against the bottom he jerked his head violently backward and at once 
lost consciousness. He died the same night, and the autopsy showed a 
transverse fracture of the body of the 5th cervical vertebra a little below 
its centre ; the cord and dura mater were intact, but there was an exten- 
sive extravasation of blood between the latter and the bone and also on 
the outside of the column. 

A servant 6 engaged in preparing a lamp raised his arm quickly to 
arrest the action of an escaping spring and felt something give way in it. 
The arm fell powerless by his side, and the greater portion of the acro- 
mion was found to have been broken off; crepitation very distinct. Re- 
covery in six weeks. 

C. Intra-uterine Fractures and Fractures during Delivery. 

Fracture of the limb of a child during its delivery through the natural 
passages of the mother is of rather frequent occurrence and is usually 
the result of manual or instrumental interference to correct a faulty pre- 
sentation or to supplement the insufficient expulsive power of the uterus. 
Such fractures belong to the class of fractures by external violence and 

1 See Fractures of the Vertebrae, chap. xiii. 2 Archives Generates, 1S38. 

3 Lancet, 1852, vol. i. p. 143. 

4 Chaussier, Revue Med. franc et etrang, t. iv. 1827, p. 264. 

5 Reveillon, Arch. Gen. de Med., 1827, t. xiii. p. 449. 

6 Wildbore, Loud. Med. Gaz.. New Series, 1846, vol. iii. p. 708. 

7 



98 ETIOLOGY OF FRACTURES. 

present no features of especial interest ; but there are others in which 
the fracture is caused by the expulsive efforts of the mother alone. An 
arm or leg is engaged between the body of" the child and the rigid parts 
of the mother and the humerus or femur broken, sometimes with an audi- 
ble snap, as the child is forced through the passage. Thus, in one case 
during the spontaneous delivery of the shoulders, the arm, which lay 
across the child's breast, was heard to snap and a fracture was found at 
its upper third; in another, a breach presentation with very forcible 
pains, the femur was broken by pressure against the symphysis pubis ; 
and in a third, where the head and left hand presented simultaneously 
and were violently forced through the pelvic outlet, a fracture of the left 
humerus was found. 

Fractures within the uterus have been caused in a few cases by a bul- 
let or sharp instrument that has at the same time perforated the abdom- 
inal wail of the mother; the interest attaching to them, however, is 
statistical rather than practical, for in the three cases collected by Gurlt 
miscarriage followed, with death of the foetus in every case, and of the 
mother in one. 

The possibility of the occurrence of fracture within the uterus as the 
result of external violence without perforation of the abdomen of the 
mother, or, in some cases, of unknown causes, has been proved by the 
delivery of children presenting fractures of different bones in various 
stages of repair. It is not always easy to say, when a child is born 
with a fracture, whether it was caused during the delivery or at an ear- 
lier period, or whether it was due to external violence or to the contrac- 
tions of the uterus. And furthermore, it is not always possible to say 
whether the apparent fracture is actually one or only a malformation, a 
defect of ossification or development, or a separation of the epiphysis 
in consequence of a syphilitic or inflammatory process. Gurlt collected 
eight cases in w r hich the causal relation between an injury received by 
the mother during pregnancy and the fracture observed in the child 
seemed to him to be clearly demonstrated, and twenty-five others in 
which more or less doubt existed as to the cause of the fracture or the 
character of the lesion. The injury in the first eight cases was either 
a fall from a height or a direct and violent blow upon the abdomen; and 
the bones broken were those of the thigh, leg, arm, and forearm, and 
the collar bone. The autopsy in three cases showed union of the frac- 
ture with undoubted callus and more or less overriding of the fragments ; 
in three others the fracture had led to suppuration and perforation of the 
skin, and in two there was a large callus (humerus and clavicle). 

'The remaining cases include some in which an undoubted fracture 
existed, but with no history of external violence, and some in which the 
coexistence of malformations threw some doubt upon the character of the 
supposed fracture, and others in which the fractures were so numerous 
and so symmetrical that they must have depended upon some general 
cause acting probably upon the epiphyseal cartilages. It has recently 
been shown by Parrot, as the result of his researches concerning the 
lesions of syphilis in infancy, that this disease has a marked tendency 
in the foetus and infant to atfect the tissues by which the growth of the 



ETIOLOGY OF FRACTURES. 99 

bone is carried on, and to weaken the connection between the shaft and 
the epiphyses. 

A woman gave birth prematurely to twins, one of which presented an 
old fracture of the femur. The bone projected more than an inch through 
the skin and was carious. About six weeks before delivery the mother, 
while making some slight exertion, heard something snap in her abdomen, 
and felt thereafter, on every movement, a pricking as by the point of a 
knife. 

Blasius 1 reported the case of a healthy, well-formed child with an 
obtuse angular deformity at the junction of the lower and middle thirds 
of one leg ; the skin presented a cicatricial-like retraction at the angle, 
where it was also unusually adherent to the bone. The ankle was free, 
the heel drawn up, and the inner border of the foot directed upwards. 
The limb was smaller than the other, and had only two toes and two 
metatarsal bones in the foot. There was a doubtful history of a blow 
received upon the abdomen during pregnancy. 

Chaussier saw in 1813 a child that died twenty-four hours after deliv- 
ery, whose skeleton presented 113 solutions of continuity, 70 of which 
were in the ribs ; a considerable number had become consolidated. 

Hedland saw in the child of a woman who had had a violent fall during 
pregnancy both femurs broken near the neck, both tibias and fibulas 
just below the knee, and both arms near the elbow. The lesions on the 
two sides corresponded closely in position. At each fracture there was 
some pinkish pus, and the ends of the bones were roughened. Probably, 
as Gurlt suggests, this was a separation of the epiphyses due to an 
inflammatory process of unknown origin. 

Gurlt 2 gives the following as the only one of the cases of so-called 
self-amputation in which there is any probability that the loss of the 
member was due to a fracture accompanied by laceration of the soft parts 
or compression of the main artery sufficient to cause gangrene. 

A pregnant woman thirty-three years old fell from the top of a ladder, 
and lay unconscious upon the ground for some time. During the follow- 
ing days blood, and afterwards bloody water, escaped from the vagina, 
but she suffered no abdominal pain and continued to feel well. Delivery 
took place in due time, eight weeks after the accident. All the left 
upper extremity of the child below the middle of the arm was lacking, 
and the end of the remaining portion of the humerus projected slightly 
through a reddish-brown, moist, but not bleeding or suppurating wound 
which formed the surface of the stump and which cicatrized promptly. 
The amputated portion of the limb came away with the afterbirth ; it 
was composed of the hand, forearm, and lower portion of the arm ; its 
skin was shrunken, the nails complete, extensive extravasation of blood 
in the subcutaneous tissue, and the end of the humerus, which presented 
a toothed surface of fracture, projected about one-fourth of an inch. 

1 Monatschrift fur Grelrartsk. unci Frauenkrankheiten, Bel. xii. 1S5S, p. 129, quoted 
by Gurlt. 

2 Loc. cit., vol. i. p. 122. 



100 SYMPTOMS AND DIAGNOSIS. 



CHAPTER V. 

SYMPTOMS AND DIAGNOSIS. 

The symptoms produced by a fracture, the facts upon the existence or 
absence of which the surgeon relies in making a diagnosis, are divided 
in accordance with the common semiological practice into two groups, 
the objective and the subjective or rational. The symptoms included in 
the former are those which can be directly observed by the surgeon ; in 
the latter they are those for his knowledge of which he has to depend 
more or less completely upon the statements of the patient. The former 
are the most important and are the only ones which have a valid claim 
to be considered pathognomonic; they include, 1st. deformity of the limb 
or part, 2d. abnormal mobility at the point of fracture, 3d. crepitation. 
The second group includes, 1st. pain, 2d. disturbance of function or loss 
of power, 3d. history of the case and of the patient. 

Except in those comparatively infrequent cases, where the injury or 
the deformity of the limb is of such a character that the diagnosis is not 
for an instant in doubt, the symptoms of a fracture are not so promi- 
nent that a careful examination can be dispensed with, and in some 
cases they are so obscure that even the most experienced and skilful 
surgeon may remain in doubt. An examination should always be con- 
ducted systematically and thoroughly, and the appearances presented 
by the injured limb should always be compared with those of its unin- 
jured fellow, both for the easier detection of slight changes and to avoid 
the mistake of thinking some chance congenital variation to be a result 
of the injury. If the pain is so great as to prevent the necessary explo- 
rations, an anaesthetic, preferably ether, should be used, especially if 
the suspected fracture is in the vicinity of a joint ; and if the swelling 
of the soft parts masks the bones and interferes with the examination, 
the decision should be postponed for a few days until the swelling shall 
have been reduced by poultices or cooling lotions. In doubtful cases 
the question should always be asked whether the affected limb or its 
fellow has suffered any previous injury that might have altered its form, 
for otherwise a sprain or a contusion in the neighborhood of a deformity 
remaining after the healing of an old fracture might be mistaken for a 
recent fracture, or the limb which is used for the purpose of comparison 
may itself have been shortened or otherwise deformed by a previous injury. 

Objective Signs. 

Deformity. — This term is here employed in its widest sense to include 
changes in the relations of the fragments of the bones to each other and 



OBJECTIVE SIGNS. 101 

the modifications in the appearance of the limb or part of the body pro- 
duced by' those changes, by the effusion of blood, and by the later inflam- 
matory processes. In other words, it includes changes in the length 
and diameter of a limb, in the form and color of a surface, in the resis- 
tance of the tissues to pressure, and in the relations of certain bony 
points or prominences to each other. 

The changes in the relations of the fragments to each other and the 
resultant modifications of the form of a limb, have been described in 
detail under the head of Displacements (Chap. III.). Many of them are 
so marked that they are recognizable by simple inspection of the part, 
while others are brought to light only by careful measurements and 
comparison with the opposite limb. These measurements are used in 
practice only to recognize longitudinal and lateral displacements and 
those by which a limb is shortened or the diameters of an articular ex- 
tremity modified. As a rule, to which there are few exceptions, men- 
suration, to be of value, requires that the injury should be confined to 
one limb, to one side of the body, in order that the other may serve as 
a standard of comparison by which the change in the first may be recog- 
nized. The reason of this is the absence of fixed proportions between 
the different parts of the skeleton, such as would enable us to calculate 
in any given case from the height of an individual, for example, the 
length of a bone or the distance between any two points. Among the 
possible exceptions to this rule are the relations of the great trochanter 
of the femur to a line drawn from the tuberosity of the ischium to the 
anterior superior spine of the ilium, and those of the styloid process of 
the radius to the lower extremity of the ulna, both of which may be 
used with considerable accuracy in cases of fracture of the neck of the 
femur or lower extremity of the radius even when the opposite limb has 
been rendered unsuitable for the purposes of comparison by disease or 
injury. 

The chief difficulty in employing mensuration is that of finding fixed 
and well-defined points upon the body between which the desired 
measurements can be made. The ones employed in fractures are bony 
prominences or edges sufficiently near the surface to be readily recog- 
nized and felt, but as they are all more or less rounded, absolute accu- 
racy in measuring the distance is impossible. 

Another cause of error or of uncertainty lies in the differences which 
have been found to exist often in the limbs of the same individual, and 
which sometimes are very considerable. The occasional existence of 
such a difference not having a traumatic or pathological origin appears 
to have been known for some time. Duparque 1 published a paper in 
1863 in which he called attention to the influence of certain professions 
in diminishing the growth of one arm, as compared with the other, and 
to the importance of the recognition of this fact in the diagnosis and 
treatment of fractures. Although he refers to it as a fact generally 
known to the profession, I do not find it mentioned in the general trea- 
tises on surgery or the special ones on fractures ; and, in this country at 
least, attention was first called to this natural asymmetry in the length of 

1 Graz. Hebdornadaire, 1863, p. 55. 



102 SYMPTOMS AND DIAGNOSIS. 

the lower limbs in a paper published in the American Journal of the 
Medical Sciences, April, 1873, by Dr. Wm, C. Cox, and inspired by 
Prof. Thomas G. Morton, of Philadelphia, and subsequently, February, 
1877, but independently, by Dr. Wight, of Brooklyn. The statements 
then made have been since confirmed by many observers, and the exist- 
ence and diagnostic importance of a normal asymmetry are now gen- 
erally recognized. Prof. Morton 1 examined 51 3 boys, from eight to 
eighteen years of age, and found inequality of the lower limbs in 272, 
varying from J inch in 91 cases, and J inch in 100, to 1J- inch in 2 cases, 
and 1-f inch in 1 case. In a personal adult case, verified by dissection 
(one of a series of 16 cases examined in the dissection room in 1877), 
the distance from the anterior superior spine of the ilium to the tip of 
the external malleolus was half an inch greater on the right side than on 
the left, and the bones showed no trace of injury ; and in a case now 
under my observation at Bellevue Hospital the left humerus is half an 
inch longer than the right. It is evident, therefore, that small differ- 
ences, say up to half an inch, must be accepted with much reserve in 
making a diagnosis, or in estimating the result after repair. 

Other difficulties and causes of error in measuring are found in the 
swelling of the soft parts of the injured limb, which may prevent the 
measuring-tape from being drawn straight, and in the varying angles 
between the axis of the limb and the line of measurement. The first is 
not likely to be great, and is still less likely to be overlooked ; but the 
latter is a frequent source of error. It is rare that the two fixed points 
between which the measurement is made are both upon the limb, or the 
bone, whose length is in question ; one of them is usually upon the 
trunk, and lies at a certain distance from the centre of motion of the 
limb. Consequently any change in the position of the limb changes the 
actual distance between the two fixed points that have been chosen. For 
example, in measuring the length of the lower extremity the points 
taken are the anterior superior spine of the ilium and the tip of the ex- 
ternal malleolus ; the former lies several inches above and to the outer 
side of the centre of motion of the coxo-femoral joint, and therefore 
when the limb is in abduction the distance between the two fixed points is 
less than when the limb is parallel to the long axis of the body. If a 
comparison is to be made between the two limbs, it is essential that their 
positions with reference to the pelvis should be the same, and therefore 
care must be taken that the ankles are equidistant from a line drawn at 
right angles to another connecting the two anterior superior spines. It 
is not sufficient that the limbs should be parallel to the long axis of the 
body, for the pelvis may be inclined to it, and a glance at fig. 57 will 
show the result of such an inclination, one limb being virtually abducted 
and the other adducted, so that while the lines A B and A B, which repre- 
sent "the actual length of the two limbs, are equal, the lines C B and C B, 
which are the ones measured by the surgeon, are unequal. If only one 
upper fixed point in the median line, as the umbilicus or the sternum, is 
used for both measurements the effect of an inclination of the pelvis 
would be still greater. 

1 Surgery in the Pennsylvania Hospital, 1880, p. 287, 



OBJECTIVE SIGNS. 



103 



Fi«?. 57. 



Similar difficulties and uncertainties exist in transverse and peripheral 
measurements of the limbs to an even greater degree. The swelling of 
the soft parts not only increases the bulk of the part, but it also obscures 
the bony prominences, and places them at a greater distance below the 
surface, so that an accurate measurement of the distance between points 
upon the opposite ' sides of a bone is practically 
impossible. Malgaigne recommends the use of 
needles or pins passed through the soft parts until 
they touch the bone as a means of measuring the 
thickness of the overlying tissues. By subtract- 
ing the sum of these measurements from the diame- 
ter of the limb at that point the breadth of the 
bone is obtained. Theoretically the method is cor- 
rect, but the practical difficulties are great, for the 
very swelling which renders the method necessary 
obscures the land-marks, and makes it impossible 
to insert the needles with accuracy at the desired 
points. For this and for angular and rotatory dis- 
placements the trained eye of the surgeon, aided 
by careful and minute consideration or palpation 
of the anatomical land-marks and comparison with 
the other limb, is the best guide, and will often 
recognize the change at the first glance. 

The appearance of the limb may be still further 
modified by an abundant extravasation of blood 
poured out from the vessels of the bone and the 
adjacent parts, and either collected in a mass or 
infiltrated among the tissues. Except when the 
bone is subcutaneous, this extravasation is not 

at first accompanied by discoloration of the surface, and is then to be 
recognized only by the greater size and firmness of the limb, or pos- 
sibly by the peculiar crackling of the coagulated blood felt when the 
part is handled, a crackling which has been compared to that of dry 
starch, or of snow compressed in the hand. The swelling may be so 
distinctly limited, and rendered so firm by coagulation or the tenseness 
of the tissues that cover it, as to give to the exploring hand the sensa- 
tion of a solid substance, and thus be mistaken for the displaced end of 
the broken bone. Malgaigne has reported a case in which he mistook 
such a collection of blood for the projecting end of a broken femur. In 
case of doubt the diagnosis could be made by the aid of acupuncture 
needles, the introduction of which through the skin would show the con- 
sistency of the mass, and prevent a collection of blood from being mis- 
taken for bone. A similar diagnostic use of needles has been suggested 
when doubt exists as to the presence of a fissure, or as to the identity or 
connections of some portion of bone, or bony prominence, that can be felt 
through the skin, but it is doubtful if much can be gained by this method 
of exploration. It is, of course, possible that the point of a needle 
might slip into a fissure or pass between two fragments in such a manner 
that it might be alternately pinched and freed by bending the limb, but 
it is improbable that the occasion would often arise when the value of the 




104 SYMPTOMS AND DIAGNOSIS. 

information to be gained would justify even the slight inconveniences of 
the exploration, except in the contingency first mentioned, that of doubt 
as to the character of an abnormal mass, and in the search for mobility 
of the fragments in the case of a suspected fracture involving a joint. 

Ecchymosis is a symptom that is rarely absent, although its appearance 
may be delayed for several days. Blood is freely poured out from the 
medullary canal and the spongy tissue of a bone, and in cases of fracture 
by indirect violence it may make its way along the muscular planes and 
first appear under the surface at a considerable distance from the seat 
of injury. Under such circumstances, its tard}^ appearance at a distance 
from a painful point upon the course of a bone, with the history of an 
injury, it raises a strong presumption of fracture, although it is by no 
means pathognomonic. In fractures by direct violence the ecchymosis 
appears promptly and at the point where the injury was received, and is 
often due as much to the contusion of the soft parts as to the fracture. 

The coexistence of an external wound is not to be lightly taken as a 
proof that the fracture is compound. The blow which has caused it 
may also have produced an indirect fracture at a considerable distance, 
or, even if the position of the fracture corresponds to that of the wound, 
the deeper soft parts may still remain undivided and prevent communi- 
cation between the two. In cases where the bone does not protrude and 
cannot be felt by cautious exploration through the wound, the diagnosis 
of a probable communication may be made if the hemorrhage is profuse, 
prolonged, and venous in character, and if it contains scattered oil-globules 
within the first twelve hours. 

In fractures communicating with joints a very notable and character- 
istic deformity is caused by the filling of the cavity of the joint with 
extravasated blood or an inflammatory effusion, the character and situa- 
tion of which are shown by its limitation within the boundaries of the 
articular capsule. 

Abnormal Mobility. — Mobility appearing after injury at a point in a 
bone where it did not previously exist, and permitting the bone to be 
lengthened, shortened, or bent at an angle, or allowing a portion of it to 
be moved while the other portion remains at rest, is pathognomonic of a 
fracture, but unfortunately it is not always present or recognizable. In 
an impacted fracture the two fragments may be so firmly wedged together 
that mobility does not exist ; and in a partial or a toothed fracture, or 
in fracture of one of two bones, as in the forearm or leg, it may be so 
slight as not to be recognizable ; and in a fracture of a short bone, or 
in one near the articular end of a long bone, one or both fragments may 
be too small to be grasped with sufficient firmness for this exploration. 
In fracture of the ribs, or sternum, or fibula, the natural elasticity or 
mobility of the bone may deceive if not taken into consideration, or 
raise a doubt if it is. 

The manipulations employed for the detection of abnormal mobility 
vary with the seat of fracture and the kind of mobility which is sought 
to be produced. In fracture of the shaft of a long bone the surgeon 
seeks first to produce an angular displacement by passing his hand under 
the limb at the supposed seat of fracture and gently raising it, or by 
grasping the two extremities of the bone firmly and moving the lower 



OBJECTIVE SIGNS. 105 

one slightly from side to side while the upper one is held stationary. 
Or* he may grasp the limb with both hands close- to the fracture, and pro- 
duce transverse displacement by moving the fragments bodily in opposite 
directions. In fracture of the shaft of the fibula a method recommended 
by Dupnytren is to place the fingers of both hands over the inner aspect 
of the limb and the thumbs against the fibula, one above, the other be- 
low, the suspected fracture ; then by making pressure alternately with 
the thumbs the independent movement of either fragment may be de 
tected. A similar manipulation can be used upon the radius or ulna. 

In fracture of the upper portion of the femur in a stout person, or of 
the neck of the humerus, or of the upper end of the tibia where a lat- 
eral or angular displacement cannot be recognized, recourse must be had 
to slight rotation of the lower portion of the limb, while the upper por- 
tion is so held that its bony prominences can be distinctly felt by the 
fingers. Abnormal mobility is recognized by the failure of the manipu- 
lation to transmit the rotatory movements to the upper fragment. The 
test is a delicate one, and it is essential that the communicated move- 
ments should be slight, for otherwise the attachments of the soft parts 
or the interlocking of the fragments may prevent the success of the ma- 
noeuvre which, moreover, for obvious reasons must fail in partial and 
impacted fractures. 

In intra-articular fracture of the lower end of the humerus or femur, 
or in fracture of an apophysis, the surgeon's aim must be to grasp each 
fragment as firmly as possible, and to move one upon the other in the 
direction of the line of fracture. 

In exceptional cases it is possible to give a fragment a tipping or see- 
saw motion ; thus, by pressing the tip of the external malleolus inward, 
when the fibula has been broken just above the ankle, the upper end of 
the lower fragment may sometimes be felt to move outward, and when 
the internal malleolus has been broken transversely a similar rocking 
movement can be given to the fragment by pressure upon its anterior and 
posterior edges. In this manoeuvre the sliding of the skin is very liable to 
be mistaken for movement of the bone, especially if the part is swollen 
and tense, and should be guarded against as far as possible by pressing 
the fingers towards each other so as to relax the skin between them. 

All these manipulations should be made cautiously, gently, and with 
close attention, and arrested as soon as the desired information is ob- 
tained, in order that the patient may not be exposed to unnecessary harm 
by rupture of remaining adhesions or by additional laceration of the soft 
parts. 

Crepitation. — This is the sound produced, or the sensation communi- 
cated to the hand of the surgeon, by the friction of broken fragments of 
bone against each other. It is as pathognomonic of fracture as is abnor- 
mal mobility, and these two symptoms usually coexist, for crepitation 
cannot be produced except by the movement of the fragments, and when 
the latter is sufficiently marked to be recognizable crepitation is rarely 
absent. 

Crepitation has been compared, for the instruction of those who have 
never felt it, to the friction or contact of various bodies, such as nuts in 
a bag, or gravel ; but these comparisons can do nothing more than con- 



106 SYMPTOMS AND DIAGNOSIS. 

vey the most general idea of the sensation, one that is little, if at all, 
more definite than that which an ordinary imagination would evolve from 
the known conditions. The simplest means of acquiring a conception of 
crepitation in default of actual practice is to break a bone or the limb of 
a dead animal and rub the fragments together with different degrees of 
force. The sensation is not the same in all cases, it runs through all the 
grades between the sharp click of two hard points or edges and the dull, 
muffled contact felt when one of the pieces, probably, is covered with 
periosteum, or the crackling and grating of comminuted fragments and 
broad surfaces. Some of its forms are practically identical with the 
friction sounds obtained by the movement of joints whose surfaces are 
altered by disease, and although it is usual to speak of a recognizable 
difference in the quality of these sensations, the one being called hard 
or rough, the other soft or smooth, the diagnosis in case of doubt must 
depend upon circumstances other than this difference. 

Crepitation is perceived rather through the hand than the ear, although 
in some cases there is a distinct sound audible to bystanders who are not 
in contact with the patient. It is to be sought by the same methods as 
abnormal mobility, and also in the ribs or flat bones by placing the palm 
of the hand over the supposed seat of fracture and pressing gently in 
different directions, or in the expectation that movements sufficient to 
produce the symptom will be communicated to the fragments by the 
respiratory efforts of the patient. Direct auscultation, with or without 
the stethoscope, is sometimes employed, but it is inferior in accuracy to 
the hand when the parts can be well grasped. It is useful in fracture of 
the ribs or sternum. Patients can usually feel the click or grating when 
the limb is handled. 

Crepitation cannot always be produced when there is a fracture. It 
is essential to its production that there should be at least two fragments 
movable at will one upon the other, and therefore its presence is con- 
ditioned, not only upon the same circumstances as that of abnormal mo- 
bility, but also upon the contact, and, in a measure, the character of the 
broken surfaces. If the fragments are completely separated by longi- 
tudinal or transverse displacement, and are not brought into contact by 
traction or pressure, if a piece of muscle or periosteum is engaged 
between them, or if sufficient time has elapsed to allow them to become 
covered with granulations, their movements will not cause crepitation, 
and it is a matter of daily experience that the same manipulation which 
produces crepitation at one moment may fail to produce it at the next. 
The reasons therefor can sometimes be observed directly in compound 
fractures of subcutaneous bones, such as the tibia, where the movements 
of the patient or the involuntary contractions of the muscles of the limb 
will be seen through the wound to change the relations of the broken 
fragments. 

The same reasons which make it undesirable to attempt a verbal de- 
scription of the sensation of crepitation apply equally to the more or less 
similar sensations produced by other conditions with which the crepita- 
tion of fracture may be confounded. The best guard against error is 
found in a knowledge of the errors to be avoided and in a careful study 
of the case with those errors borne in mind. Those other conditions are: 



SUBJECTIVE OR RATIONAL SIGNS. 107 

roughening of the articular surfaces of neighboring joints, which pro- 
duces "friction sounds" when they are moved; inflammation of the 
sheaths of tendons or of bursae, giving rise to a fine crackling when they 
are handled ; emphysema due either to the escape of air into the tissues 
from a wounded lung or to decomposition with the production of gas ; the 
crackling of coagulated blood, and a pleuritic friction sound when heard 
after an injury to -the wall of the thorax. 

Subjective or Rational Signs. 

Diminution, or total loss, of the functions of the limb or part involved 
is a common result of fracture, but as it may also be occasioned by a 
simple contusion it is not pathognomonic of the former lesion. The imme- 
diate causes of this loss of power are various : it may be due to the 
breaking of the bone between the points of attachment of the muscles 
which control it and the fixed point about which its normal movements 
take place ; or it may be due to pain excited by the slightest motion of 
the fragments or by the contraction of the bruised muscles, or to the 
paralyzing effect of the dread of pain upon the will of the patient. An 
extreme instance of the latter was recently furnished in a patient who 
came under my care for fracture of the olecranon, and in whom commu- 
nicated movements of pronation and supination were absolutely prevented 
by muscular rigidity during the first twenty-four hours, although made 
with entire freedom afterwards. The loss of function may be complete, 
as after fracture of the shaft of the femur or of the humerus, or it may 
be so slight as to be overlooked ; and the former is no more a proof of 
the severity of the injury than the latter is of its unimportance, for while 
on the one hand a severe contusion, or even the mere thought of having 
received a fracture, may prevent voluntary movements of a limb, on the 
other, patients may walk a considerable distance or raise the leg in bed 
after having broken the neck of the femur or the tibia. In a personal 
case, a man 66 years old, broke the neck of the femur by a fall clown a 
flight of stairs, he rose without assistance and walked down another 
flight before he lost control of the limb. The fracture was found at the 
autopsy to be a smooth, non-impacted, transverse fracture at the junction 
of the head and neck of the bone. Many similar cases are on record, 
and Stanley 1 has recorded a still more remarkable case of a man who 
walked four miles with the help only of a cane after his tibia and fibula 
had been broken by the kick of a horse. 

Other modifying circumstances are found in delirium, which, by ren- 
dering the patient indifferent to pain, allows him to move the broken 
limb, and in injury of a joint by dislocation or sprain which compels 
immobility. 

Pain, either spontaneous, or on pressure, or on movement of the 
limb, is a constant acompaniment of fracture, and under some circum- 
stances is a valuable aid to diagnosis, especially when the fracture has 
been caused by indirect violence or by muscular action. In suspected 
fractures by direct violence, its diagnostic value is less because the pain 

1 London Med. Gazette, 1844, vol. i. p. 273. Qnoted by Grurlt. 



108 SYMPTOMS AND DIAGNOSIS. 

may be due to injury of the soft parts, especially the periosteum, occa- 
sioned by the blow. It should be sought for by gentle pressure with 
the finger along the course of the bone, and if it is found on repeated 
examination always at the same point, and if the area within which it is 
found or is most severe is small or is distinctly circumscribed, I am in 
the habit of treating it as a sign of probable fracture when, from the 
circumstances of the case, the other and more positive signs are not to 
be certainly expected, as in some fractures at the lower end of the 
radius or of the tibia or fibula. In like manner a localized pain, excited 
by slight communicated rotatory movements of the limb at a point in the 
shaft of a long bone where there is no contusion, is a sign of probable 
fracture. Malgaigne says he has on several occasions seen a diagnosis 
of fracture made upon this symptom alone confirmed by the subsequent 
course of the case. 

The history of a case, with reference to the diagnosis, includes earlier 
injuries which may have modified the form of the limb, the nature of the 
accident and the method of fracture, and occasionally the snap heard by 
the patient or bystanders at the moment the injury was received. The 
latter is probably produced very commonly, but as a rule it passes un- 
perceived because the attention of the individual is occupied by the fall 
or the impending blow which causes the fracture. Consequently it is more 
commonly observed in fractures by muscular action than in others. As 
a similar sound may be caused by the rupture of a tendon the absence of 
this latter lesion must be established before the diagnosis of fracture can 
be made simply upon the occurrence of an audible snap at the moment 
of the accident. 

Reasons have been given already to show why it is necessary to make 
inquiries concerning previous injury to the limb, so as to avoid an error 
in diagnosis ; the danger to be avoided is that of supposing a pre-exist- 
ing deformity to have been produced by recent violence which has really 
caused only a contusion or sprain at the seat of a former injury. 

A knowledge of the mode in which the injury has been received is of 
importance in determining the diagnostic value to be attached to some of 
the symptoms previously described, especially those of pain, ecchymosis, 
and swelling ; and when, as is frequently the case, the patient is unable 
to say positively what portion of the limb received the blow, an exami- 
nation of the surface may show an abrasion or contusion or a stain left 
by contact with the ground which indicates the point in question. If a 
limited point of pain, or of greatest pain, is then found at a distance the 
existence of a fracture by indirect violence is probable, while if the pain 
is found only at the spot where the blow was received its diagnostic value 
is less. The degree of the causative violence is of less importance, in 
view both of the difficulty of correctly estimating it and of the varying 
fragility of the bones which often makes fracture possible by slight 
causes. 

These are the facts upon which a diagnosis must be based. As a gen- 
eral rule, they should all be sought for systematically, even when the 
diagnosis is not obscure, because it is only by this means that the sur- 
geon can acquire the necessary familiarity with them which will make it 
possible for him to recognize them in doubtful cases. When the surgeon 



SUBJECTIVE OR RATIONAL SIGNS. 109 

is called to a case of suspected fracture he should begin his examination 
by inquiring into all the circumstances of the injury, not only for the 
purpose of giving the patient time to recover from the excitement pro- 
duced by his arrival and the dread of a painful examination, as Prof. 
Hamilton has wisely urged, but also to obtain the information which he 
may need later when the patient is, perhaps, under the influence of an 
anaesthetic. 

In proceeding to the direct examination of the injured part, the im- 
portance of avoiding all needless pain and rough handling must be kept 
constantly in mind ;,the clothing is first removed, in doubtful cases from 
the opposite limb as well as from the injured one, and the part inspected 
for the discovery of any contusion, ecchymosis, swelling, or deformity 
recognizable by the eye. If a deformity is found its extent may be de- 
termined in suitable cases by measurement. Then the fingers are lightly 
passed along the course of the bones which may be the seat of the injury, 
in search of a painful point, or of any irregularity in outline ; if the in- 
jury is in the vicinity of a joint, the ends of the bones which form it are 
carefully explored, their relations to each other compared with those of 
the corresponding bones on the opposite side, and the functions of the 
joint examined by communicating cautious movements to it. 

Crepitation and abnormal mobility are next to be sought for by the 
methods heretofore described, and an anaesthetic employed if necessary. 

If a fracture has been detected, and if it is associated with a wound 
of the soft parts that probably makes it compound, the wound may be 
explored, preferably with the finger, for the purpose of determining the 
character of the fracture and of removing loose splinters of bone ; but 
this is an exploration that should never be lightly undertaken, and in 
making it the surgeon should feel that he may, perhaps, do the patient 
harm that will not be fully compensated for by the information he 
obtains. 



110 



REPAIR OF FRACTURES 



CHAPTER VI. 



REPAIR OF FRACTURES. 

The clinical phenomena which accompany the healing process after 
fracture of a bone vary with its character, and especially with its com- 
plications. In the simpler cases, when the injured limb has been prop- 
erly secured by splints and bandages, the patient is usually free from 
pain and fever ; he eats and sleeps well, disturbed only by the confine- 
ment to which he is subjected, and by more or less vague sensations of 
weight and uneasiness in the limb, or, perhaps, occasionally by involun- 
tary twitchings of the muscles. A few blebs may form on the surface 
of the limb, but seldom cause any uneasiness. During the forty-eight 
hours immediately following the receipt of the injury he usually shows 
some rise of temperature, but it seldom reaches any great height or lasts 
long. A number of thermometrical observations in simple fractures, un- 
accompanied by much displacement, were made by Dr. Stickler 1 and Dr. 
Root, in my services at the Presbyterian and Bellevue Hospitals, and 
showed as light rise always. The accompanying thermograph, fig. 58, 

is from one of Dr. Root's cases, 
Fig. 58. a simple fracture of the leg. 

Within a few hours after the 
receipt of the injury the limb 
swells, especially in the neigh- 
borhood of the fracture, and 
this swelling may be accom- 
panied by puffiness of the cor- 
responding hand or foot, due to 
interference with the return cir- 
culation. The swelling dimin- 
ishes in a few days, and then a 
firm, rounded mass can be felt 
about the bone at the point of 
fracture, which is tender on pressure, and, during the following weeks, 
becomes gradually smaller and harder. As this mass hardens the abnor- 
mal mobility, which may have been noticed immediately after the in- 
jury, diminishes, and finally disappears, and the union is then complete, 
although not so strong as it will subsequently become. The hard mass 
which has effected the union continues to diminish for months afterwards, 
perhaps for years, so that in the simplest cases where, for example, the 
periosteum has not been torn, no trace of it will remain ; but usually it 
can be detected after scraping the bone, or sawing it lengthwise. 



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1 N. Y. Medical Record, 1882. 



KEPAIR OF FRACTURES. 



Ill 



In the severer cases, those marked by more displacement of the frag- 
ments, shattering of the bones, and violence of the reaction, the same 
sequence of phenomena is presented, but there is more pain, more 
swelling, and more general disturbance of the system. It has also been 
recently observed by Riedel (Deutsche Zeitschrift fur Chirurgie, vol. x. 
p. 539) that in these cases and also in the less severe ones, albumen 
and casts are present in the urine during the first few days following the 
injury, and he describes in particular a kind of cast not found in the 
common diseases of the kidney, a brown granular cast of medium size. 
He attributes this intercurrent nephritis and the fever to the absorption 
of the serum of the blood extravasated and coagulated at the seat of 
fracture. He also found free fat in the urine in 42 per cent, of the 
cases examined. 

The greater the displacement of the fragments and the consequent 
laceration of the soft parts at the time of the injury, and the more acute 
the onset ot the inflammatory processes, within certain limits, the larger 
will be the mass (callus) which forms at the seat of fracture, both tem- 
porarily and permanently, and the greater the permanent deformity. 

Usually the symptoms do not long remain acute, the oedema and red- 
ness diminish, the skin assumes a yellow color for a considerable distance 
on all sides, especially towards the trunk, the bandages are found loose 
at the daily examination in consequence of the subsidence of the swelling, 
the patient loses the pain and malaise previously felt, he eats and sleeps 
well, and convalescence is fairly established. But if some cause of 
irritation persists, if the tissues are constantly subjected to fresh lacera- 
tion by the unreduced fragments kept constantly in motion by the invol- 
untary contractions of the muscles or the delirious agitation of the patient, 
the prognosis becomes less favorable because the processes of the first 
stage are then more likely to terminate in suppuration instead of resolu- 
tion. This suppuration may be confined to the seat of the fracture, the 

Fi<?. 59. 



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fcimple fracture becoming compound on the 9th day. 



112 REPAIR OF FRACTURES. 

ends of the fragments lying bare in the cavity of the abscess, or it may 
spread up the limb accompanied by sloughing of the connective tissue 
and the formation of abscesses at various points, the deadly acute puru- 
lent infiltration of the older writers. Gangrene of the skin over the 
fracture may occur during the earlier stages as the result either of the 
direct violence that caused the fracture or of the pressure of a displaced 
fragment. Finally, nervous symptoms may make their appearance, 
either as an attack of delirium tremens within the first few days or as 
tetanus at a later period. 

The progress of a case may be modified in an important manner by 
articular complications having their origin in direct communication 
between the fracture and a neighboring joint or in the extension to the 
latter of the inflammatory processes set up by the main injury. In the 
former case the symptoms pointing to the implication of the joint appear 
very promptly, the synovial sac becomes distended by .an effusion of 
synovia mixed with blood in greater or less proportions, and pain on 
motion is extreme and referred directly to the joint. The injury, espe- 
cially if the joint is a large one, is much more severe than a simple frac- 
ture and has a correspondingly greater effect upon the general condition 
of the patient; his temperature rises, his pulse quickens, and his diges- 
tion becomes disordered. The arthritis persists for several weeks, 
even under favorable circumstances, and either terminates in resolution 
after gradual abatement of the symptoms and with loss or diminution of 
the functions of the joint, due in part to changes in the relations of the 
surfaces to each other, or it goes on to suppuration and puts the life of 
the patient in peril. In some cases, as in fracture of the neck of the 
femur, union may fail entirely, and in others it may be fibrous instead 
of bony, results which, however, are not associated with any material 
change in the early clinical history of the case. 

When the arthritis is the result not of a direct implication of the joint 
in the fracture, but only of an extension to it of the inflammatory pro- 
cesses set up by the injury its course is less severe. The joint becomes 
distended by an effusion of synovia, and pain, both spontaneous and on 
motion, is felt in it, but the consequences are usually limited to the for- 
mation of adhesions and peri-articular thickening. Suppuration follows 
only in rare cases. 

In compound fractures the same series of phenomena is observed as in 
simple fractures, modified more or less by the coexistence of the wound.. 
The liability to destructive inflammatory processes, to suppuration at 
the seat of fracture, to burrowing of pus, and to the other complications 
above mentioned is much greater, but as it is sometimes possible to ob- 
tain prompt union of the wound and thus transform the fracture into a 
simple one the course may be as mild and free from complications as in 
the other class of cases. In other cases the wound remains open on the 
surface but its deeper parts unite, and thus the transformation into a 
simple fracture is again accomplished and the course is as mild as before 
with such slight modifications as are due to the coexistence of a super- 
ficial wound. If union is not obtained, if the wound suppurates, the 
suppurative process extends to and involves the bone, giving rise either 
to a mild, uncomplicated osteitis marked by moderate fever, more or less 



REPAIR OF FRACTURES. 113 

abundant suppuration, and formation of abscesses in the neighborhood, 
or to an acute osteo-myelitis ushered in by a chill, accompanied by high 
fever, and likely to terminate fatally by septicaemia or pyaemia. In the 
commoner class of cases, those in which the seat of fracture suppurates 
but in which the dangerous septicaemic complications do not appear, the 
general condition of the patient is not much affected. After the suppu- 
ration is fairly established the fever disappears so completely that any 
subsequent rise of temperature is to be regarded as an indication that 
something unusual or irregular is occurring in the wound, that drainage 
is imperfect, or that a new abscess is forming. The callus forms rapidly 
and exuberantly, the wound fills up but is slow to close, and fistulae lead- 
ing down to loose splinters or to necrosed portions of callus whose vessels 
have been obstructed by condensation of the tissue may persist indefi- 
nitely. 

Among the symptoms peculiar to this variety are the projection of the 
bone through the wound and hemorrhage. The latter may be either 
arterial or venous, primary or recurring, and so profuse as to place the 
patient's life in immediate danger. A condition of collapse or shock, 
marked by palor of the surface, small pulse, nausea, restlessness, and, 
perhaps, a sighing respiration, may either be produced by this loss of 
blood, or may be the manifestation of the injury done to the nervous 
system or the abdominal viscera by the original violence, which in these 
extreme cases is far in excess of that usually concerned in the produc- 
tion of simple fractures. This condition may be followed by reaction, 
or it may persist until death closes the scene, after a few hours. 

The period of time necessary to the repair of a fracture varies with 
the age of the individual, the bone involved, and the nature of the frac- 
ture ; and the time at which the restoration of the functions of the part 
can be pronounced complete is always remote, and often is never reached. 
Malgaigne says that bone for bone, and fracture for fracture, repair in 
children requires only half as much time as it does in adults, and that 
except for this neither age nor sex presents any differences, an opinion 
that has been accepted by subsequent writers. He also says that the 
bones of the lower limb require more time for repair than those of the 
upper limb, and the latter more than the bones of the face ; a fracture 
near the middle of the shaft unites more slowly than one at the extrem- 
ity of the bone, and a fracture with permanent displacement more slowly 
than one in which the fragments are retained in their normal relations to 
each other. Union may be delayed far beyond the usual time by excep- 
tional conditions, which will be considered in a subsequent chapter, such 
as the interposition of a portion of muscle between the fragments, or by 
constitutional affections, or occasionally under circumstances where the 
cause cannot be recognized. 

Even after firm union has taken place between the fragments, there 
remain changes in the limb, disabilities or weaknesses, whose slow dis- 
appearance prolongs the period of convalescence, or whose permanence 
renders a complete return to the condition existing before the fracture 
impossible. The limb is usually shrunken, and its muscles wasted and 
feeble ; the skin is dry and has a tendency to become congested on slight 
provocation, such as exposure to the air, or a dependent position. There 



11 -L REPAIR OF FRACTURES. 

is stiffness of the hand or foot of the broken limb, especially of the latter 
after walking ; the neighboring joints are stiff and tender in consequence 
of the prolonged immobility and of adhesions formed within them or the 
sheaths of the tendons ; and this stiffness and tenderness may persist 
until the end of life in the old and arthritic , even when the joint has not 
been directly involved in the injury. 

Anatomo-pathological JP7'ocesses. — Bone is one of those tissues whose 
cicatrices are composed of a substance closely resembling, or identical 
with, the original tissue. The ends of a broken bone become reunited 
by bone, and this new bone is formed out of materials furnished by the 
bone itself, its marrow and periosteum, and the adjoining soft parts. The 
phenomena which accompany "and are instrumental in producing this 
repair have been known more or less completely since observation and 
experiment took the place of pure speculation in medical science, but the 
diversity in the views held concerning their origin, nature, and purpose 
has been extreme, and exists, in a measure, even at the present time, 
although accurate and well-devised experimentation, aided by perfected 
means of observation, has resolved most of the problems and harmonized 
much that was contradictory. A brief account of the stages through 
which the study and teaching of the subject have passed seems desirable, 
to enable the reader more easily to fit that which is new on to that which 
is old, and to interpret and use the terms and observations of the older 
classical writers in the light of our more precise and detailed knowledge. 

The speculative theories of the ancients do not need mention beyond 
the fact that Galen's, which attributed repair to a "bone-jaice" poured 
out from the broken ends of the bones, was the one generally accepted 
at the end of the seventeenth century when direct observation and ex- 
periment upon animals were first employed, and the real study of the 
subject began. Antonio de Heyde 1 recorded, in 1684, the conclusions 
he had drawn from experiments made upon frogs ; he thought that the 
callus was formed by the solidification of the blood poured out between 
the fragments. Du Hamel, 2 experimenting upon pigeons and sheep, and 
interpreting the facts in the light of previous study of the method of re- 
pair in trees (he seems not to have been a physician, and certainly not a 
surgeon), formed the opinion that the periosteum, aided somewhat by 
the marrow, was the active agent of repair. His observations were 
numerous and accurate ; he noticed the new formation of bone under the 
periosteum for some distance from the fracture and the smoothness of 
the bone wherever the periosteum had been stripped from it ; also the 
tumefaction of the periosteum and the interposition of a thin gelatinous 
layer between it and the bone. He even placed, as all do now, the espe- 
cial osteogenetic quality only in the innermost layer of the periosteum, 
or in the gelatinous layer just mentioned which adjoins and is produced 
by it, and attributed to them the normal growth of a bone in thickness, 

1 Ex his experiments forsan probatur callum generari e sanguine evasato, cujus 
fluidis particulis sensim exhalantibus reliqnum ossis formam assumit, quod promo- 
veri potest ab lialitu ex ossis fracti extremis deciduo. Quoted by Du Hamel in His- 
toire et Memoires de l'Academie Royale des Sciences, 1741, p. 222. 

2 Hist, et Mem. de l'Acad. Royale des Sciences, 1741, pp. 97 and 222, and, 1743, pp. 
69, 87, 111, and 288. 



REPAIR OF FRACTURES. 115 

comparing it to the growth of a tree by the formation of wood under the 
bark. He denied that the cortical layer could reunite, and having in 
one case found a union so perfect that he could not trace the line of 
fracture after having sawed the bone, he boiled the specimen in a strong 
solution of lye, and had the satisfaction of seeing it fall into two pieces 
and thus confirm, as he supposed, his opinion. He claimed also that the 
lamellae of the spongy tissue and on the border of the marrow were cov- 
ered by a membrane that had its origin in, and possessed the functions of, 
the periosteum. In fact, he anticipated by one hundred years the dis- 
coveries of Syme, Heine, and Oilier, although it was left to these latter 
experimenters to furnish the actual demonstration. 

A few years later, 1748-1767, Haller, Boehmer, and Detleef opposed 
Du Hamel's views, and reasserted the former theory of the " bone- 
juice" ; according to them this juice w T as poured out by the bone, became 
gelatinous, then cartilaginous, and finally bony ; and at about the same 
time an opinion first published by Jean Louis Petit, to the effect that the 
callus is formed by granulation tissue, as a cicatrix of the soft parts is, 
was again put forward and warmly defended by Bordenhave and others. 

About a hundred years after the publication of De Heyde's experi- 
ments, his theory that the callus had its origin in the blood poured out 
between the bones at the time of the fracture, was revived by John Hun- 
ter, and thoroughly elaborated a few years 'later, with the aid of experi- 
ment and microscopical examination, by Howship, 1 whose descriptions 
are remarkably accurate and detailed, although his interpretation of the 
facts was erroneous. 

Of these theories all except the one last mentioned are partly true, 
and together they furnish the basis of all subsequent ones. They erred 
because they were too exclusive or too indefinite, but being based upon 
experiment and observation they furnished sound data for speculation, 
and indicated new lines of research, w T hich have since been freely used 
by theorizers, or followed out by investigators. The main facts, as far 
at least acs the gross appearances were concerned, were fairly before the 
profession at the beginning of the present century, and upon them and 
the pathological and clinical facts furnished by his large experience 
Dupuytren constructed his theory of the development of the callus, a 
theory complete in all details, logical in its development, seductive in its 
fulness and verisimilitude, lacking only in accuracy. As the terms and, 
in a measure, the ideas of this theory are current at the present time, 
it requires description. 

Dupuytren brought again into prominence Du Hamel's theory of the 
part played by the periosteum, a theory which had been almost lost sight 
of in the general acceptance, under the able advocacy of Bichat and 
Scarpa, of that of repair by granulations springing from the broken 
bones, and extended it by attributing the same power to the adjoining 
soft parts when the exercise of that power was necessary. He described 
two calluses, the one temporary or "provisional," the other permanent 
or " definitive." The former was composed of two parts, the volumi- 
nous ovoid mass of spongy bone that incloses and binds together the 

1 Med. Chirurg. Trans., 1818, vol. ix. p. 143. 



116 REPAIR OF FRACTURES. 

broken ends of the bone and to which the name " ensheathing callus" 
has been given by the English authors, and a central bony plug uniting 
the two portions of the medullary canal. The broken bone itself, that 
is, its compact layer, did not share, according to Dupuytren, in the pro- 
duction of this callus and had no immediate union with it; the fragments 
were simply imbedded in a mass of spongy bone produced by the joint 
action of the marrow, periosteum, connective tissue, and even the mus- 
cles themselves, which made up by its bulk for its lack of compactness 
and kept the pieces immovable until a small bond of firm, compact bone, 
the definitive callus, had formed between and restored the direct conti- 
nuity of the cylindrical shell. He divided the period of formation and 
development into five stages 1 : 1st, the stage of irritation, lasting until 
the eighth or tenth day, during which extravasations of blood take place 
between the fragments and into the adjoining tissues, the connective 
tissue swells and becomes more firmly united with the periosteum and 
muscles, the marrow thickens, and a viscid substance or a mass of pink 
granulations fills the space between the fragments ; 2d, the cartilaginous 
stage, lasting until the twentieth or twenty-fifth day, during which the 
external callus is formed from the periosteum and soft parts and is trans- 
formed into cartilage, the change beginning in the centre and extending 
outwards, and the medullary canal is closed by a bony plug formed 
within it ; 3d, the stage of spongy ossification, lasting until the fiftieth or 
sixtieth day, during which the provisional callus is completed by its 
transformation into spongy bone ; 4th, the stage of compact ossification, 
lasting until the fifth or sixth month, during which the substance between 
the fragments, which appears as an interposed line of different color, 
grows firmer and whiter and is finally changed into compact bone, estab- 
lishing firm union between them ; 5th, the stage of disappearance of the 
provisional callus, lasting until the tenth or twelfth month, during which 
the external callus and the medullary plug are absorbed. 

All subsequent theories and descriptions of the process of repair are 
modifications or amplifications of one or more of those above mentioned, 
so far as the origin and nature of the process are concerned, and owe 
their individuality to the importance given by them to one or the other 
element in the process or to the effort to establish differences based upon 
the degree and character of the displacement of the fragments. The 
discrepancies are more apparent than real, and the observed clinical differ- 
ences can all be referred to variations in one and the same fundamental 
process, variations imposed upon it by the relations of the periosteum 
and fragments to each other. 

The process of repair after fracture is fundamentally the same as that 
of repair after other injury, and its phenomena differ only in degree from 
those of normal nutrition and growth of bone. It is the normal nutri- 
tive process exaggerated by the irritation of the traumatism, and as such 
involves all the constituent parts of the bone. It begins with the multi- 
plication of the cellular elements of the periosteum, marrow, Haversian 
canals, and lacuna? of the spongy tissue ; this multiplication produces a 
mass of granulations which fill the gap between the fragments and are 

1 Leqons orales de clinique cliirurgicale, vol. ii. p. 49. 



REPAIR OF FRACTURES. 117 

transformed into bone, sometimes directly, sometimes after having passed 
through a cartilaginous stage. This mass of new bone, at first spongy 
in its structure, that is, composed of irregular lamellae or plates circum- 
scribing relatively large lacunae filled with bloodvessels and medullary 
elements, — becomes firmer and more compact in some portions by in- 
crease in thickness of the lamellae and consequent reduction in size of 
the lacunae, the process known as "condensing osteitis," a stage of pro- 
ductive osteitis, and observed constantly in the foetus as well as under 
many pathological conditions, and becomes thinner and weaker in other 
portions until it finally disappears by the converse process, diminution 
of the lamellae through their absorption by the medullary elements of the 
lacunae, "rarefying osteitis," another stage of productive or simple ostei- 
tis and also found in the normal development of a bone and in pathological 
conditions. There is nothing in the process more mysterious than this, 
nothing that requires the intervention of a special Deus ex machina, 
nothing that distinguishes it fundamentally from that of the repair of any 
other member of the great group of the connective tissues. The vari- 
ations depend upon differences in the degree of the injury or in the 
position of the fragments, which require disproportionate amounts of work 
to be done by the different parts. The details of the process will appear 
upon examination of the manner in which it is carried on after simple 
fracture of the shaft of a long bone, an example which has the advantage 
of illustrating the behavior of all the different elements and of being 
both more complete and more open to experimental study than fractures 
of short bones or of the spongy extremities of long ones. 

When a fracture takes place the cylindrical shell is broken along an 
irregular line and probably always with the production of splinters of 
greater or less size. The marrow is bruised by the pressure of the 
broken ends as they slip past or are driven into each other. The peri- 
osteum is usually torn, but the extent of its rupture has probably been 
largely overestimated even when there is much displacement of the frag- 
ments. Oilier 1 was the first to call especial attention to the preservation 
of its continuity at some part of the periphery of the bone, and to the 

Fi^. 60. 




Periosteal bridge" after fracture of a rib. 



fact that when a lateral or longitudinal displacement has occurred the 
membrane is stripped partly off one fragment, but without having its con- 
tinuity broken, and thus forms a band uniting the two fragments. To 



1 Traite de la Regeneration des Os. 



118 REPAIR OF FRACTURES. 

this band he gave the name of "periosteal bridge." Fig. 60 represents a 
periosteal bridge of this kind as I found it eight days after the fracture 
of a rib. The same rib showed at another point of fracture the perios- 
teal envelope complete except for a distance of one-fourth of an inch. 
The patient was an old man and the fractures were caused bj a fall from 
the fourth story of a house. In another case, an extensive depressed 
fracture of the skull in a lad of IT, I found the pericranium untorn but 
separated from the bone over the entire area of the depression by effused 
blood. In compound fractures with protrusion of a fragment it is com- 
mon to find the projecting end and other portions accessible to the touch 
denuded of periosteum ; and remembering also that the periosteum is 
rather loosely attached to the bone and, on the other hand, is continuous 
by an intimate structural union with the overlying soft parts, I am in- 
clined to believe that its continuity is largely preserved in all cases, or 
that if temporarily destroyed at some points by perforation by a frag- 
ment it is practically restored when the displacement is corrected. The 
observed liberty of motion is given to the fragments by the stripping up 
of the periosteum from one or both of them, and the extent of this denu- 
dation depends upon that of the displacement. This being so, the 
periosteum would furnish a tubular sheath connecting the ends of the 
fragments and all splinters except those that are entirely loose, guiding 
and limiting the formation of the new tissue that is to establish the 
ultimate union. Whether this sheath is complete or not, the existence 
of the periosteal bridge indicated by Oilier is of extreme importance 
because it maintains the connection between the fragments by means of 
a tissue whose activity in the production of bone is abundantly estab- 
lished. The position and form of the callus in numerous specimens of 
union with displacement have seemed to me to indicate clearly the posi- 
tion and agency of a periosteal bridge. 

At the same time blood is poured out from the torn vessels of the 
bone into the gap between the fragments, and from the vessels of the 
adjoining soft parts into the interstices among the muscles. This blood 
is gradually absorbed during the first few days following the receipt of 
the injury, and at the same time the effects of the traumatism are mani- 
fested in the usual inflammatory oedema of the limb and the infiltration 
of a thick viscid liquid into the soft tissues immediately adjoining the 
seat of the fracture, the beginning of the firm ovoid mass which can 
always be felt at this point. The periosteum becomes much thicker, 
softer, and more vascular, a thin layer of gelatinous or viscid liquid is 
found between it and the bone for the distance of a few lines from the 
edge of the fracture or from the point to which the membrane has been 
stripped up, and at the more distant limit of this layer the surface of 
the bone promptly becomes roughened by the formation of patches of 
new bone. The portions of the periosteum which have been stripped off, 
those which form complete or incomplete periosteal bridges, and the 
lacerated tissues which form the wall of the cavity in which the ends of 
the bone lie granulate and pour out lymph into this cavity to mingle with 
the partly coagulated blood remaining there. 

The marrow shares in this production of granulations ; and the cells 
of the connective tissue external to the periosteum share for a greater 



REPAIR OF FRACTURES 



119 



or less distance in the irritation and by their proliferation bind together 
all the adjoining parts, muscles, tendons, and fascite, in one firm, com- 
pact mass. The compact layer of bone, the cylindrical shell of the shaft, 
feels the same influence and reacts in the same manner, but much more 
slowly in consequence of the scantiness of its available cellular elements. 
Its surface and that of its broken ends soon show pink points which 
enlarge and send .out granulations to join those already produced by the 
periosteum and marrow, and thus there is formed between the separated 
fragments a bond of union which is actually continuous, almost from the 
beginning, with all their constituent parts. It has no strength, no ability 
to resist an external strain, such as is possessed by bone ; that strength 
will be given to it by ossification, but meanwhile its weakness is supple- 
mented by the inflammatory tumefaction of the neighboring parts which 
impedes the movement of the fragments, and by the enforced rest to 
which the limb is condemned by the nature of the injury. The size and 
character of this bond vary with the degree of displacement ; if the frag- 
ments remain nearly in their original relations to each other the bond is 
short and symmetrical, the granulations springing from the marrow meet 
and unite in the centre of the gap, while the thickened periosteum 
passes directly from one fragment to the other, remaining adherent to 
them or separated only by a layer of effused blood. If longitudinal and 
lateral displacement occurs and persists the bond passes obliquely from 
the outer surface of one fragment to that of the other and is much more 
complete at some points of the periphery than at others. Tnus, in 
figure 62, which represents the condition found by Gurlt on the seventh 



Fig. 61. 





Callus of a pigeon's bone on the 6th day. 
(Du Harael.) 



Tibia of rabbit, 7th day ; a. blood : b. carti- 
laginous callus; c. muscles. (Gurlt.) 



day after fracture of the tibia of a rabbit, the firmest union is by the 
cartilaginous band crossing the angle at b and formed apparently by the 
thickening of a periosteal bridge. On the opposite side of the lower frag- 
ment the beginning of an incomplete band of similar structure is seen. 



120 



REPAIR OF FRACTURES 



The formative action thus begun is rapidly carried on, and principally 
by the periosteum and marrow. When the fragments are kept end to 
end an ovoicl mass of tissue having the consistency of jelly and a pearly 
white appearance, and continuous above and below with the periosteum, 
envelops them, the so-called "ensheathing callus." This mass is formed 



Fte. 63. 




Callus oa the loch day. (Howship.) 

not solely by granulations springing from the under side of the perios- 
teum, but also by the thickening of the connective tissue on the outer 
side, including even that which surrounds the adjoining muscular bandies 
and fibres. Composed at first of embryonal elements, it soon becomes 
cartilaginous ; then lime salts are deposited at different points within it, 
and finally it is transformed into bone. 

The granulations that spring from the marrow ossify without passing 
through the cartilaginous stage, and the process here apparently begins, 
as in other pathological conditions, at the fine lamellae which lie upon the 
inner side of the compact shell. The new lamellae extend across the 
canal, soon occluding it entirely, and also out into the interval to meet 
those coming from the other fragment. Thus is formed the internal or 
medullary plug. 

The granulations lying in the annular interval between the two portions 
of the compact tissue, the "intermediate substance" which, according to 
Dupuytren, was to form the definitive callus, ossify as the rest do after 
passing through the cartilaginous stage, and become united to and con- 
tinuous with the compact tissue, but they originate in the periosteum or 
the adjoining subperiosteal layer. The lateness of this union, which 
does not become firm for several months, is due to the slight vascularity 
of the compact tissue, to the small size and limited number of the chan- 
nels in which the bloodvessels and cellular elements are contained. The 
capillaries which open upon the surface of the fracture are occluded by 
coagulation, and the cell proliferation which begins behind the clots can 
make its way to the surface and form granulations there only after 
absorption of a certain amount of the bone itself. This absorption takes 
place either along the sides of the channels (Haversian canals) leading 
directly down to the surface of the fracture, or along a line parallel to 
this surface ; in the latter case a scale of bone is separated or " exfo- 
liated," as is often seen in a compound fracture or after an amputation 
or resection. In a simple fracture such a scale, if formed, probably 
undergoes complete absorption, or perhaps may be imbedded in the callus 



REPAIR OF FRACTURES 



121 



as splinters of larger size sometimes are. The compact tissue, therefore, 
has to pass through a preliminary or preparatory stage of rarefying 
osteitis which approximates its structure to that of the spongy bone of 
the callus, so that at a certain time we find on longitudinal section through 
the two fragments and the callus that the original compact tissue on each 
side becomes gradually more and more spongy or vascular as the line of 
fracture is approached, shading off into the callus in such a manner that 
this line can scarcely be recognized. Ultimately this spongy bone is 




Callus and adjoining rarefied bone. (Howship. 



made denser by the deposit of new bone on the surfaces of the lacunae 
and the consequent diminution of the latter, and thus its structure be- 
comes more nearly identical with that of the compact tissue, although it 
never presents the same regularity and symmetry in the size and arrange- 
ment of its canals. 

Fragments of the cortical layer broken off at the time of the injury 
may remain attached to the periosteum, preserve their vitality, share in 
the same processes, and form a part, often an important one, of the 
callus. There is reason to believe also that even after they have been 
entirely detached they may form new connections with the soft parts 
and granulations, and preserve, perhaps even renew, their life. Such 
fragments have been found imbedded so deeply in a callus that no other 
explanation than that of complete detachment can well be accepted. 
Howship describes and figures one, and Gurlt another and very remark- 
able one, figure 65. Quite recently the possibility of this preservation 
has been established by experiment upon animals. Portions of the shaft 
of a long bone have been chiseled off, separated entirely from the soft 
parts, and replaced in contact with the bone ; the wound of the soft parts 
united promptly under antiseptic treatment, and subsequent examination 
after the lapse of a sufficient period of time showed reestablishment of 
vascular connection and preservation of the vitality of the fragments. 1 

' Centralblatt fur Chirurgie, 1880, No. 44. 



122 



REPAIR OF FRACTURES 



Fis:. 65. 



Bergmann presented at the 10th Congress of the German Gesellschaft 
fiir Chirurgie 1 a specimen of gunshot wound of the knee-joint in which a 
fragment of the external condyle of the femur had 
been driven into the crucial ligament and had 
healed there ; the length of time that had elapsed 
since the receipt of the injury is not given. The 
patient died of dysentery. 

It is also known that fragments may long re- 
main without vascular connection imbedded in a 
callus as well-tolerated foreign bodies. After 
the lapse of months or even years, and from 
unknown causes, they sometimes cause irritation; 
an abscess forms, the bone softens about them, 
and either they are cast out spontaneously or 
they remain, provoking an interminable suppura- 
tion, until removed by the surgeon. This is 
frequently observed after gunshot fractures. 

It occasionally happens that the callus does 
not ossify, and in some very exceptional cases 
the bone is entirely absorbed for a very consider- 
able distance on each side of the seat of fracture. 
The causes are not fully understood. The dif- 

Fis. 6Q. 



Fracture of the neck of the 
femur and of the shaft. A 
splinter, a, 5 inches long- and 
nearly 1 inch wide, composed 
of the cortical layer, has been 
turned completely about its 
long axis and become united, 
with its original periosteal 
surface in contact with the 
other fragments. (Figured by 
Gurlt from the Museum of the 
Koyal College of Surgeons, 
England, No. 454.) 





Portion of humerus removed in an operation for pseudarthrosis. 



ference in the process consists in an entire or partial absence of produc- 
tive osteitis, and in an excess of the rarefying osteitis ; the consequence 
of the former is the development of the granulations into fibrous tissue, 
with occasionally an irregular outgrowth from the end of the bone ; 
that of the latter is loss of substance of the bone itself, reducing its 
thickness or its length, and sometimes causing it to terminate in a point. 
Figure Q6 represents a portion of bone which I removed in an operation 
for pseudarthrosis of the humerus ; it shows a central cavity formed 
within the bone, a perforation near its lower edge, and a considerable 
prolongation of one angle. The end of the lower fragment was conical. 



1 Beilage zum Centralblatt fiir Chirurgie, 1881, No. 20, p. 14. 



REPAIR OF FRACTURES. 123 

In a second variety of pseudarthrosis the fibrous bond extends not as 
a solid cord between the fragments, but as a cylindrical one, similar to 
the capsule or ligaments of a joint, and the ends of the bones become 
eburnated, smooth, and rounded by friction upon each other, or covered 
by a layer of cartilage. 

The diminution of the callus and the rounding off of projecting points 
or ends, which take place slowly during the months following the injury, 
are effected by a continuation of the same process of rarefying osteitis 
w T hich begins so early and prepares the bones for union. Sir James 
Paget 1 mentions a case in which the size and prominence of the absorbed 
portion of bone made it possible to observe the process in its different 
stages. U A patient in the Exeter Hospital had a bad comminuted 
fracture of the leg, and a long spike of the tibia, including part of the 
spine, could not be reduced to its exact level, but continued sensibly ele- 
vated, though in its due direction. At the end of five weeks (union 
having taken place) the end of the spike began to soften ; at six, it was 
quite soft and flexible, like a thin cartilage ; at the conclusion of the 
seventh week it was blunt and shrunken. Six months later, the carti- 
laginous tip had disappeared, and the spike was rounded off." The term 
"cartilaginous" must be understood to refer only to the consistency of 
the tissue, for no cartilage is formed in this retrograde process. The 
granulations are formed by the multiplication of the soft cellular ele- 
ments lining the canals of the bone and develop directly into fibrous 
tissue. 

When the, fracture is compound the details of the reparative process 
are different to this extent, that the callus does not pass through the 
preliminary cartilaginous stage at any point where suppuration has oc- 
curred. The formation of the medullary plug is not affected, the granu- 
lations there being transformed directly into bone as they are in simple 
fractures ; the difference is in the external or ensheathing callus. The 
reason of this difference as shown by experiment 2 lies in the destruction 
of the periosteum by the suppurative process, in the destruction, that is, 
of the only tissue whose granulations pass through the cartilaginous 
stage in forming the callus. 

CD O 

The process is slower than after a simple fracture because the suppu- 
ration of the wound delays or prevents the formation of much of the ex- 
ternal callus and throws most of the labor upon the bone itself, which, as 
has been shown, is the least capable to perform it. It is easy to watch 
the process. The ends of the bone are seen lying bare and white in the 
wound ; a mass of pink granulations forms at the limit of the denudation 
and advances slowly across the bared surface ; the broken surface remains 
for a time quiescent, then granulations spring from it, beginning at the 
points nearest the medullary canal and spreading slowly towards the outer 
edge ; the wound gradually fills up with these granulations, the bone is 
covered in, and cicatrization follows. 

In less fortunate cases a portion of the bared bone dies and is cast off 

1 Lectures on Surgical Pathology, 3d ed., Pliila. 1871, p. 191. 

2 Rigal and Vignal, Comptes Rendus de l'Acad. des Sciences, 1880, vol. xc. p. 
1218. 



124 REPAIR OF FRACTURES. 

by the formation of a line of demarcation which can sometimes be seen at 
the edge of the granulations but which more commonly is hidden by them. 
It must not be thought that all the bare white bone seen in such a wound 
is dead, even after it has remained unchanged in appearance for several 
weeks. Its surface may indeed be dead, but, the interior is often alive 
and able to cast off the dead superficial scale without aid. The granu- 
lations that form between the living and the dead parts seem sometimes 
to dissolve and absorb the latter if they are small and thin, or, if not, to 
slowly bear them to the surface and cast them out. 

The callus thus formed is larger and more irregular than after simple 
fracture ; it remains tender and sensitive for a long time, and is covered 
by an adherent scar at the seat of the wound if the bone is superficial. 
Fragments formed at the time of the accident and remaining attached to 
the periosteum usually preserve their vitality ; if not, they become de- 
tached after a time and are found loose in the wound, or become shut 
in by the callus and prolong the suppuration indefinitely. In this latter 
case the constant irritation due to the presence of the foreign body, the 
existence of sinuses, and the burrowing of the pus interfere with the 
evolution of the callus. Instead of undergoing a gradual and uniform 
diminution and condensation it becomes eburnated at some points and en- 
tirely absorbed at others, irregular prominences appear on its surface 
or follow the lines of attached tendons and fasciae, and its interior is oc- 
cupied by cavities of various sizes usually suppurating and in communi- 
cation with the exterior. The walls of these cavities are sometimes 
carious, sometimes covered with feeble granulations that furnish a con- 
stant discharge and show no tendency to fill the cavity and ossify. 
Malgaigne extracts from the Memoires de l'Academie de Chirurgie a 
case of gunshot fracture of the femur below the trochanter, the persis- 
tent suppuration from which caused the death of the patient in five 
years. All the sinuses led into a large cavity in the bulky and irregu- 
lar callus, and this cavity was lined at all points by a thick, soft, whitish 
membrane, while the burrowing of the pus on the outside had denuded 
the great trochanter and rendered it and the hip joint carious. 

In compound fractures, accompanied by much shortening of the bone 
and laceration of the soft parts, the inevitable suppuration of the latter 
is usually so prolonged and so extensive that most of the smaller frag- 
ments cannot preserve their vitality, and their loss creates a gap often 
too large to be filled by the new bone. The granulations become fibrous 
instead of bony, and the only union between the two ends of the bone 
is by a dense band of connective tissue. 

The duration of the process of repair after a compound fracture varies 
greatly, as may be inferred from what has already been said. If the 
external wound closes without deep suppuration the course is the same 
as that of a simple fracture ; if, on the other hand, necrosed fragments 
become imprisoned in the callus the resulting fistulae persist indefinitely. 
As a general rule, however, a much longer time is required for the estab- 
lishment of firm union than after simple fracture. 

In the short and flat bones which have no medullary canal, and in the 
spongy extremities of the long ones, the details of the process of repair 
are modified only by the absence of the marrow. The same granula- 



REPAIR OF FRACTURES 



125 



tions form upon the broken surfaces of the bone, and the torn periosteum 
and soft parts unite and ossify. The external callus in the ribs is often 
large, because of the mobility of the parts, but in the other cases men- 
tioned there is usually but little projection of the callus beyond the out- 
line of the bone, probably because the displacement and laceration are 
less, and possibly, in part, because the periosteum, being more adherent 
than it is upon the shaft and more generally perforated by tendons and 
ligaments, is not stripped up to any £reat extent, but is torn directly 
through along the line of fracture. When the fragments are replaced 
the edges of the periosteum unite promptly and confine the mass of 
granulations within a narrower space than when this membrane has been 
stripped up and is held away from the bone by an interposed clot of 
blood. In short, the condition of the parts is more likely to be favor- 
able to the work, for the surfaces of contact are broad, uniform in struc- 
ture, and with a large proportion of spongy bone, from which the granu- 
lations can spring immediately without the aid of preliminary rarefaction, 
and the fragments are not liable to be disturbed by the involuntary mus- 
cular twitchings or movements of the patient. 

In fractures involving joints the form and origin of the callus are 
again modified by anatomical differences, of which the absence of peri- 
osteum and other soft tissues on the articular surface is the chief. The 
fracture communicates more or less freely with the cavity of the joint, 
and the synovia bathes the granulations and interferes with their devel- 



Fis:. 67. 



Fig. 





Bony union of the patella. (Bryant.) 



Comminuted fracture of the patella. Bony union. 
Exuberant callus at several points. (Gurlt.) 



opment, as an excess of liquid usually does. The absence of periosteum 
on the articular surface prevents the formation of an external callus on 
that side, and union takes place by granulations arising directly from 
the fractured surfaces and by an external callus at the extra-articular 
parts of the fracture. To this extent the details are the same as in re- 
pair after fracture of the spongy bones, and the differences in result are 
mainly in the completeness of the union, which is often fibrous, and 
sometimes fails. When the conditions are favorable and bony union is 
obtained the line of the fracture is always marked on the articular sur- 
face by the absence of cartilage over it, and usually by a groove. The 
fracture of the cartilage does not heal by the formation of new cartilage ; 
usually the callus is covered at this point by a firm, white layer of fibrous 



126 



REPAIR OF FRACTURES 



tissue resembling in its gross appearance the cartilage with which it is 
continuous, but not having its structure, and sometimes the bone is bare. 
In exceptional cases the callus is exuberant and grows out beyond the 
level of the cartilage, forming an irregular mass in the place of the 
usual groove. 

Failure of union, which is not rare in articular fractures, has been 
attributed exclusively, but apparently without sufficient reason, to the 
action of the synovia upon the granulations. The cause lies rather in 
the separation or the mobility of the fragments, and also, in cases where 



Fis. 69. 



Fig. 70. 




Absorption of the neck of the femur after 
intra-capsular fracture. (Gurlt.) 




Intra-articular fracture of the lower end of 
the humerus, with exuberant callus, especially 
in front. 



the fracture lies entirely within the cavity of the joint, as in intra-cap- 
sular fracture of the neck of the femur, to insufficient blood-supply, and 
to the absence of soft parts capable of forming an external callus to unite 
and steady the fragments while union is taking place between them. 
In extreme displacement, such as complete rotation of the head of the 
humerus after intra-capsular fracture of its neck, union must take place, 
if at all, between the broken surface of the lower fragment and the articu- 
lar surface of the upper rotated one, and the materials for it must be 
furnished almost exclusively by the former, since the vascular supply to 
the other is carried on only by the vessels of such portions of the syno- 
vial sac as may have preserved their attachments to it. Partial absorp- 
tion of the head, neck, and broken surface of the trochanter is common 
after fracture of the neck of the femur, and is effected by the rarefying 
process already described. 

Exuberance of the callus, both external and intermediate, is a frequent 
cause of diminution of the functions of the joint by destroying the nor- 
mal relations of the articular surfaces, by filling up normal depressions, 
and by creating abnormal prominences. These results are usually beyond 



REPAIR OF FRACTURES 



127 



the control of the surgeon, and the latter are most common in the young, 
whose power of producing bone is greatest. Occasionally the produc- 
tive process excited by the fracture extends far beyond the limits of the 
latter, and not only may the joint itself be entirely obliterated by fusion 
of the bones which constitute it, but the process may also spread to, and 
produce the same result in, neighboring joints, as in the case represented 
in fig. 70. 

Bones which lie parallel and close to each other, as those of the fore- 
arm and leg and the ribs, may become united by an exuberant callus 
when either one or both are broken. This consolidation occurs most 
frequently when both bones are broken at the same level, and when the 
displacement of one or more of the fragments diminishes the normal 
interval between them. The lacerated soft parts granulate as has been 
described, the mass of granulations developed about one fracture becomes 
continuous with that developed about the other, and ossification follows. 
The presence of an interosseous membrane favors this undesirable result, 
for this tissue has the same tendency to ossify that is shown by other 
fasciae and tendons in the presence of a productive osteitis. The effect 



Fisr. 71. 



Fig. 72. 



Fisr. 73. 




Bony ank losis of the root and ankk 
after fracture of the leg. (Gurlt.) 





Fracture of the forearm, an- 
gular displacement, and union 
between the bones. 



Fracture of the tore- 
arm, with formation of a 
lateral joint. 



of this consolidation is, of course, to prevent independent motion of the 
two bones, and while of no importance in the leg and of little, if any, 
in the ribs, it produces a very serious disability in the forearm by causing 
the loss of the movements of pronation and supination. It occasionally 



128 REPAIR OF FRACTURES. 

happens, when two bones are broken at the same level, that the calluses 
grow into contact with each other but do not unite. Their adjoining sur- 
faces are smooth and together form a sort of lateral joint, which may allow 
movement of one upon the other. In the specimen represented in fig. 
72, pronation and supination were lost, but the loss was apparently clue 
as much to the angular displacement of the bones as to the exuberant 
callus. 

Finally, separation of the fragments may lead to total failure of union, 
to fibrous union, or to insufficient union by a bony bridge. The latter 
is found in combinations of extreme longitudinal and lateral displacements, 
and differs from normal repair only in the insufficient formation or ossi- 
fication of the granulations. Fibrous union is most common in the old, 
after fractures which have not been immobilized properly or for a sufficient 
length of time, and in articular fractures with separation, of which the 
most common examples are furnished by fractures of the patella and of 

Fig. 74. 







Fracture of the olecranon ; fibrous union. (Malgaigne.) 

apophyses to which powerful muscles are attached, as the olecranon or 
the coronoid process of the ulna. The tonicity of the muscle tends to 
draw the fragment away, and the latter is so small or so situated that 
efficient measures to counteract this action cannot be employed. The 
first steps of the process of repair may take place as usual and granula- 
tions form between the fragments, but they develop into fibrous tissue 
instead of bone, apparently because the ossific influence of the fragments 
from which they arise or to which they are attached cannot exert itself 
over the entire distance. In other cases the granulations seem- to be 
furnished mainly by the soft parts, and their development is naturally 
into fibrous tissue rather than into bone. 

When the line of fracture follows that of a still existing epiphyseal 
cartilage either wholly or in part, and the fragments are not displaced, 
union takes place apparently as readily as after simple fracture, but 
nothing positive is known of the details of the process. There is reason 
to believe that the injury does not necessarily interfere with the subse- 
quent growth of the bone : the layer of cartilage may remain unossified 
and perform its functions as before ; but it is known from the results of 
experiments upon animals and from some cases of inflammatory disease 
affecting the ends of the bones, that the effect of irritation of the epi- 
physeal cartilage is sometimes to hasten its ossification and thus arrest 
the growth of the limb. This last result must certainly be produced 



REPAIR OF FRACTURES. 129 

when the epiphysis is dislocated by the fracture and is not restored to 
its place, and experience has shown the possibility of a similar arrest by 
premature ossification due to the irritation of a fracture. (See p. 51.) 

Mr. Bryant 1 mentions a case of arrest of growth of the humerus 
amounting to three and a half inches following fracture of the shaft at 
the age of eight years, which he attributes to injury of the nutrient 
artery. Gurlt quotes a case of separation of the upper epiphysis of the 
humerus which showed, on dissection three years afterwards, a false joint 
between the fragments. The head of the bone was united to the neck 
of the scapula, and the movements of the limb were free. 

1 Surgery, 3d Am. ed., p. 833. 



130 REMOTE CONSEQUENCES OF FRACTURE. 



CHAPTER VII. 

COMPLICATIONS AND REMOTE CONSEQUENCES OF FRACTURE. 

Under this title will be described the traumatic complications that 
arise more or less promptly after fracture, although not peculiar to that 
class of injuries, and the later changes observed in the form and functions 
of the injured limb after union has been obtained, its occasional sensi- 
tiveness, and irregularities in the form and evolution of the callus. 

A fractured limb is far from having regained its former appearance 
and its functions at the time when union between the fragments may first 
be said to be complete. It is shrunken, its skin dry, rough, and scaly. 
If a lower limb it swells and reddens when the patient begins to walk, 
the swelling being most marked and firm about the ankle ; its joints are 
stiff and sometimes immovable, and it is often painful after use or during 
changes in the weather. These defects persist for a longer or shorter 
time, and some of them may be permanent. 

Stiffness of the joints is observed not only in those articulations that 
have been directly involved in the fracture, but also in others at a dis- 
tance. Sufficient mention has been made of the causes of the former in 
the preceding chapter ; so far as the stiffness is due to permanent changes 
in the form of the articular surfaces and in the relations of the different 
parts of the joint to each other, changes which oppose a mechanical 
obstacle to the movements of the bones, it is practically permanent, and 
little, if any, improvement is to be expected. Occasionally the ligaments 
lengthen under forced use, or projecting surfaces of bone are in part 
absorbed, and the range of motion may thereby be slightly increased. 

The cause of the stiffness that is so generally observed in contiguous 
joints not directly involved in the fracture, has been the subject of much 
controversy, and it is probable that there are several of them. Exam- 
ination after death or after amputation of the limb, has frequently shown 
evident signs of inflammation of the joint: injection and thickening of 
the capsule, softness of the cartilage, and sometimes intra-articular bands 
of recent formation. Quite recently Gosselin and Berger 1 reported three 
autopsies which proved, they claimed, that this arthritis is due to the pas- 
sage into the joint of extra vasated blood coming from the fracture. This 
opinion was considered much too exclusive by their colleagues in the 
Society, although possibly correct in some cases. The arthritis, which 
is especially common in the knee after fracture of the leg or thigh, pre- 
sents two clinical forms ; in one it occurs immediately after the injury, 
in the other only after the lapse of a few days. The first is undoubtedly 
due in some cases to an associated sprain, in others possibly to the causes 

1 Bulletins de la Societe de Chirurgie, 1878, pp. 6 and 336. 



EEMOTE CONSEQUENCES OF FRACTURE. 131 

described by Gosselin and Berger ; the second is the result of the exten- 
sion employed to overcome or prevent shortening. Malgaigne attributed 
the stiffness in the knee to the extended position of the joint and to 
retraction of the ligamentum patellae, and fortified the opinion by refer- 
ence to the rarity of stiffness in the elbow after fracture of the shaft of 
the humerus, which is habitually treated with the forearm flexed. But 
it is undeniable that the same stiffness is found after treatment of fracture 
of the thigh in the flexed position, and is absent when the limb is immo- 
bilized in extension for other reasons than fracture, and therefore Mal- 
gaigne's explanation must be considered too exclusive. It has been 
observed in the very numerous osteotomies that have been recently done 
for the relief of genu valgum, that after division of the femur above the 
condyles the patients are usually able to move the knee freely as soon 
as the splint is removed, and this fact indicates, in my judgment, that 
the stiffness observed after accidental fracture is probably due in great 
part to an arthritis excited by a concomitant sprain. The stiffness of the 
fingers found so constantly after fracture of the radius or forearm seems 
to be due in part to the implication of the sheaths of the tendons in the 
inflammation about the injury, and it is certainly increased by the ex- 
tended position. In other cases the pain is referred, when an attempt 
is made to flex the limb, to the seat of fracture, and thus points to impli- 
cation of the fibres of the muscle .in the callus or in the inflammatory 
thickening around it. Retraction of the peri-articular tissues and liga- 
ments, the result of prolonged immobility, is also demonstrable in many 
cases. 

The stiffness is, as a rule, most marked and most persistent in the aged 
and rheumatic; it is usually temporary, but may disappear very slowly, 
or last for years. Malgaigne speaks of a case of stiffness of the knee 
following fracture of the shaft of the femur, and persisting for twenty- 
one years. 

Atrophy of the limb is found very frequently after fracture, and is usually 
slight. It is said by Gosselin 1 to be permanent and to affect not only 
the segment of the limb that has been fractured, but also that w T hich is 
above or below. In cases where a large nerve has been injured, or 
where the callus is exuberant and painful, this atrophy may be very 
marked, and is then unquestionably due to the influence of the affected 
nerves ; but in the common slighter cases the cause is not well under- 
stood. Gosselin's experiments and those of one of his students, Lejeune, 
who had also an opportunity to weigh the muscles of a man who died 
some time after having received a fracture of the thigh, showed that the 
atrophy involved the muscles themselves, and not merely the adipose 
tissue of the limb; each muscle when deprived of its fat weighed less 
than the corresponding one of the unbroken limb. Malgaigne attributed 
it to the prolonged compression by the retentive apparatus, but Gosselin 
found it equally marked in two cases of the fracture of the elbow that 
had been treated by continuous irrigation without bandages. He there- 
fore rejects compression as a cause, and also the prolonged immobility 
invoked by others, and suggests that the atrophy is due u to a change 

1 Gazette Hebdoinadaire, 1859, and Clinique Chirurgicale, 1872. 



132 REMOTE CONSEQUENCES OF FRACTURE. 

in the distribution of the nutritive materials which is a consequence of 
the process of consolidation. Not only does the fracture draw towards 
itself a greater quantity of these materials, but the callus itself, when 
once formed, and, after its completion, the hyperostosis require a greater 
proportion for their nourishment." This explanation has not been re- 
ceived favorably, and does not seem to be either sufficient or in accord 
with other allied conditions. The atrophy appears to be most marked 
after fractures involving, or in the immediate neighborhood of, joints. 
A thesis by Sabatie, 1 gives a full bibliography of the subject and dis- 
cusses the different factors, but fails to make the cause apparent. 

Obliteration of tlie large veins in the neighborhood of a fracture is 
thought to be a rather common occurrence, and to be the cause of the 
oedema which is so constantly noticed in the limb during convalescence. 
Its immediate cause lies sometimes in pressure upon, or injury to, the 
vein, by one of the fragments or splinters, and sometimes in the spread 
to it of the inflammation of the adjoining parts, which, by setting up phle- 
bitis, leads to coagulation of the blood within the vessel. Gosselin has 
suggested also, as a possible cause of this phlebitis, the passage into the 
larger veins of irritating materials coming from the inflamed marrow of 
the bone. The oedema which results and persists until the vein becomes 
free, or a sufficient collateral circulation is established, is troublesome 
and annoying, but it is rare for any serious consequence to ensue. 
Nevertheless, a few cases of fatal embolism due to the dislodgment of 
the clot have been reported, and, therefore, the possibility of this acci- 
dent should be noted. The first reported case, so far as I know, was by 
Yirchow, in 1846, in Traube's Beitrage zur experimentalen Pathologie, 
fatal pulmonary embolism after extra-capsular fracture of the neck of 
the femur. Durodie 2 collected eight other cases, in which the death oc- 
curred twice on the 22d day, and once each on the 16th, 30th, 35th, 
47th, 50th, and 57th days ; one case was a fracture of the thigh, the 
others of the leg. Mr. Southam published in the Lancet, March 1st, 
1879, the particulars of two cases of simple fracture of the leg in which 
death was caused by an embolus lodging in the pulmonary artery, as 
proved by post-mortem examination. In one, Pott's fracture, death 
took place on the 18th day, in the other, fracture of the fibula, on the 
16th day. 

The symptoms are the usual ones of pulmonary embolism ; the patient, 
without any warning, suddenly grows livid, or very pale, with great dys- 
pnoea, anxiety, and precordial distress, and dies, usually, in a few mo- 
ments. 

It is much more common to observe the occurrence of small emboli 
accompanied by more or less severe symptoms, but terminating in re- 
covery. The symptoms are sudden dyspnoea, cough, sometimes with 
bloody sputa, and the physical signs of localized consolidation of the 
lung. The risk of this accident is sufficient to make it necessary to 
avoid all active movements and all rubbing of the limb when there is 
reason to suspect the presence of a thrombus in a large vein. 

1 De l'Atrophie Musculaire Consecutive aux Fractures. These de Paris, 1878, No. 9. 

2 Etude sur les Thromboses et l'Embolie veineuse dans les Contusions et les Frac- 
tures. These de Paris, 1874. No. 326, p. 55. 



REMOTE CONSEQUENCES OF FRACTURE. 133 

Fat embolism, too, is thought to be an occasional cause of death after 
fracture, not recognized until within the last twenty years. The fat set 
free by the crushing of the marrow makes its way into the veins and 
lymphatics and lodges mainly in the capillaries of the lungs, but also in 
those of other viscera, where it is easily recognized by the aid of the 
microscope, especially if the section is prepared by staining with osmic 
acid. 

The first occasion on which this condition was recognized as the im- 
mediate cause of death after fracture was in 1864, and as the case fairly 
represents one of the clinical forms of this complication, I reproduce it 
from the account given by Flournoy. 1 A man was brought to the surgi- 
cal clinic at Konigsberg with a simple, transverse fracture of the tibia, 
caused by the kick of a horse. At first, all went well, but the next day 
he complained of great weakness, became comatose", and died 36 hours 
after the accident. The autopsy, made by Yon Recklinghausen, showed 
numerous small ecchymoses in the brain, heart, skin of the shoulder, 
bladder, conjunctiva, and retina ; hemorrhagic infiltration of the marrow 
of the tibia for an inch on each side of the fracture, and clotted blood 
between the fragments; great oedema of the lungs. The microscope re- 
vealed fat in the capillaries, small arteries, and apparently also in the 
veins throughout the body, but especially in the lungs, where the ob- 
struction caused by it was so extensive that only a very few of the capil- 
laries seemed to have remained pervious for the blood. Von Reckling- 
hausen at once attributed the death of the patient to fat embolism, and 
under his inspiration Busch 2 soon afterwards published an article upon 
the subject which shares with one of Wagner's 3 the honor of first 
establishing the causal relation between fat embolism and early death 
after fracture. 

The following three cases represent other features and illustrate the 
rapidity with which fatal embolism may occur and the occasional resem- 
blance between its symptoms and those of traumatic shock. 

1. A healthy man 32 years old 4 broke his right femur near the mid- 
dle by a fall from a scaffold late one afternoon, and was taken at once 
to the hospital where a splint and ice-bag were applied. The next day 
he was free from pain, but in the evening his temperature had risen to 
103J°, and his pulse and respiration were quickened. During the night 
his noisy breathing attracted the attention of the nurse, and he was found 
to be comatose, with deep, frequent respirations, loud, coarse rales, 
percussion-note clear and slightly tympanitic ; pulse 100, full and strong ; 
pupils contracted; face cyanotic ; reflex irritability lost. Later a few 
convulsive twitchings were observed in the arms ; profuse perspiration ; 
tracheal rales. He died thirty-eight hours after the accident. 

The autopsy showed the small arteries and capillaries of the lungs 
filled so extensively with clear liquid fat that Czerny considered it evi- 
dently the cause of death. A considerable number of similar branched 

1 L'Embolie graisseuse. These de Strasbourg, 1878. 

2 Virchow's Archiv, 1866, p. 321. 

3 Archiv der Heilkunde, 1865, vol. vi. p. 481. 

4 Czerny, Berliner klinische Wochenschrift, 1875, p. 594. 



134 COMPLICATIONS OF FRACTURE. 

fat emboli were found in the brain, corresponding usually to small ecchy- 
moses ; and some of. the vessels of the kidney, especially those of the 
glomeruli, were filled in like manner. There was also marked oedema 
of the lungs. . 

2. A man 47 years old 1 sustained a compound fracture of the right 
leg and simple fracture of five ribs on the left side by the caving in of 
an embankment. When brought to the hospital eight hours afterwards 
there was emphysema of the entire anterior surface of the left side of 
the chest ; pulse full, strong, and slow ; respiration normal. Lister dress- 
ing of the compound fracture. 

The next day he had no fever, and the wound was aseptic. At 9J 
P. M., while feeling perfectly well, he suddenly lost consciousness; 
breathing slow and snoring ; pulse 42, full and strong ; percussion note 
over the chest slightly tympanitic but otherwise normal ; respiration 
harsh. He died one and a half hours afterwards, thirty hours after the 
accident. 

The lungs were found hypergemic and slightly cedematous, with nume- 
rous punctiform ecchymoses under the pleura and in their substance, 
and very extensive plugging of their capillaries and arterioles with fat. 
Many of the alveoli were more or less completely filled with large, round, 
fatty cells, and others contained masses of red blood-corpuscles entangled 
in fibrin. Subperitoneal hemorrhage, liver fatty, spleen and kidneys 
normal except for some fat in the vessels of the glomeruli of the latter, 
no lesion in the brain. 

3. A lad 19 years old 2 was run over by a heavy wagon and received 
compound fractures of the right thigh and leg, and a simple fracture 
of the left thigh. He lost much blood from the torn arteries of the leg, 
and was brought to the hospital at 4 P. M. in a condition of extreme 
collapse ; pulse 100 and small ; respirations not quickened ; foot cold 
and insensitive. The thigh, was amputated through the upper third. 
At 10 P. M. the breathing became rapid, without fever, and the patient 
died with increasing dyspnoea and tracheal rales an hour and a half after 
midnight. The lungs showed numerous ecclrymoses scattered through 
their substance, with extreme fat embolism ; the liver was pale ; the 
spleen firm and full of blood ; fat was found in all the glomeruli of the 
kidneys. 

It is probable that fat embolism occurs to a greater or less extent in 
all fractures, for its occurrence seems to require only the bruising of 
the marrow, the laceration of small vessels, and the existence of a cer- 
tain amount of pressure to force the liberated fat into the open capilla- 
ries or veins. All these conditions are present in fracture, and the 
capillaries of bone are particularly fit for this absorption because they 
are inclosed in bony walls which protect them from lateral pressure. 
It follows, therefore, and the conclusion is borne out by experiment, 
that fat embolism is not necessarily dangerous. So far as can be infer- 
red from the post-mortem examinations in some cases of death by an in- 
tercurrent cause after fracture and from the results of experiment, fat 

• Riedel, Deutsche Zeitsclirift fur Clrirurgie, 1877, vol. viii. p. 572. 
2 Idem, p. 575. 



COMPLICATIONS OF FRACTURE. 135 

emboli may disappear entirely from the lungs within three weeks after 
their formation, leaving behind them no recognizable traces of their 
presence and having given rise to no inflammatory lesions. The cases 
quoted above are all examples of death by obstruction of the pulmonary 
circulation within a few hours after the injury, but there are other cases 
in which death took place at a much later period, on the 6th, 8th, 10th, 
and 11th days, as the result apparently of the ecchymoses and the in- 
flammatory processes set up in the lungs and brain by the emboli. The 
following case from Riedel's paper is an example : — 

A man, 41 years old, of alcoholic habits, was brought to the hospital 
three days after he had received a comminuted fracture of the neck of 
the femur and the great trochanter. The following day he developed 
delirium tremens and jaundice, which persisted until his death two days 
afterwards. At the last he was somnolent, with a small rapid pulse. 
The autopsy showed ecchymoses in the heart under the pericardium and 
in the lungs under the pleura, oelema of the lungs, partial consolidation 
of both lower lobes, and extensive fat embolism ; the glomeruli of the 
kidneys, and the afferent and efferent vessels completely filled with fat. 

These facts, the numerous ecchymoses in many organs, and the devel- 
opment of localized pneumonia in the cases that survived a few days, are 
thought to indicate that the graver prognosis of severe fractures in the 
old and the alcoholic is due, in part at least, to fat embolism. Their 
hearts are weak, less able to force the fat through the capillaries, and 
their lungs, brains, and kidneys are less able to withstand the local trau- 
matisms or the altered conditions of nutrition produced by the plugging 
of the vessels ; and it is not without reason that some of the writers 
upon this subject have suggested that the dreaded "hypostatic" pneu- 
monia may depend quite as much upon this complication as upon the de- 
cubitus which has heretofore been considered its efficient cause, and 
that delirium tremens or nervosum may also be a secondary effect. It 
is only proper to add that a recent writer upon the subject, Wiener, 1 con- 
siders fat emboli as without influence in producing secondary effects, an 
opinion which is shared by Dr. Peabody, the accomplished pathologist 
of the New York Hospital. 

The symptoms in the acute and rapidly fatal forms resemble those of 
shock, and Czerny suggests that many deaths heretofore attributed to 
shock, traumatic delirium, or even contusion of the brain were really due 
to fat embolism. The differential diagnosis is here to be made, accord- 
ing to the same surgeon, by the intercurrence between the accident and 
the appearance of the symptoms of a period during which the patient 
seems to be doing well. The symptoms are varied and not very distinc- 
tive. The first one may be a sudden attack of extreme dyspnoea followed 
by oedema of the lungs, or a feeling of weakness without dyspnoea but 
with coarse rales, cyanosis, and a quick feeble pulse, or delirium, or 
coma. The constant signs, those upon which the diagnosis must be 
made, if at all, are those of disturbance of the pulmonary, and later of 
the general, circulation, occurring in the first day or two, and accompa- 
nied by a rapid change for the worse in the patient's condition. Exami- 

1 Wesen imd Scliicksal der Fett-Enibolie, Leipzig, 1879. 



136 COMPLICATIONS OF FRACTURE. 

nation of the urine, especially of that passed on the morning after the 
receipt of the injury, may disclose the presence in it of a few drops of 
fat. 

The only treatment to be attempted is that directed to the vital indi- 
cation, the relief of the pulmonary oedema. We are unable to remove 
the fat from the capillaries when it has once lodged in them, and our 
efforts must, therefore, be directed mainly to prevention. The broken 
limb must be kept quiet, in order that the laceration of the marrow and 
the extravasation of blood may not be increased; and as the embolism 
occurs promptly, amputation, whenever necessary, should be performed 
with the least possible delay. 

There are a number of other complications, not peculiar to fractures, 
but occurring also after other injuries, most of which are of great gravity 
and make their appearance, if at all, soon after the accident. It seems 
appropriate to consider them briefly here, before taking up the later 
complications which find their sole cause in the injury to the bone. 
They are: extravasation of blood, including traumatic aneurism and 
hemorrhage, emphysema, septicaemia, gangrene, pyaemia, tetanus, and 
delirium. 

Extravasation of blood takes place in every fracture, and even when 
quite extensive is usually without importance and requires no treatment. 
But when the blood escapes in large quantities in consequence of severe 
crushing of the soft parts or of the rupture of a large vein or artery it 
may endanger the patient's life, or render necessary the amputation of the 
limb. 

Extravasations of exceptional size may form under the fascia, or be- 
tween it and the skin. In the latter case they are commonly due to the 
action of a sliding force which has torn the skin away from the fascia 
and ruptured a large number of the small perforating veins, and, perhaps, 
some of the large cutaneous ones ; the blood may pass along the limb to 
a considerable distance, discoloring the integument, or it may collect as 
a distinctly circumscribed fluctuating swelling, or the blood may come 
from deeper sources, the fracture itself, and especially the muscles torn 
by the displaced fragments or crushed by the original violence. In 
simple fractures the source of the bleeding is usually in doubt, and under 
such circumstances no active treatment of this symptom is necessary 
beyond a moderate elastic compression of the parts to prevent further 
extravasation and favor absorption. Serious questions associated with 
the symptoms may arise if the original cause of the extravasation is a 
severe and extensive contusion of the limb or injury to the main artery, 
such as the necessity for amputation, in the former, and for formal ope- 
rations upon the wounded vessel in the latter. 

An extravasation may, by the slowness of its absorption, prolong the 
period of convalescence, for the coagulation of a large quantity of blood 
may leave a hard clot which will provoke suppuration. In some cases 
it is desirable to remove the fluid blood or the serum left after coagu- 
lation by the aspirator, but this should not be done in recent cases; and 
if suppuration occurs, or is impending, the collection must be treated as 
an abscess and opened freely. Usually, before this extreme measure 
becomes necessary, the process of repair will have advanced sufficiently 



COMPLICATIONS OF FRACTURE. 137 

to protect the patient from the especial dangers of a compound fracture, 
and the broken ends of the bones will be covered with granulations, or 
imbedded in a well advanced callus. 

Hemorrhage from a compound fracture is often severe, and sometimes 
dangerous, although it is rare that a large vessel is wounded. The 
blood comes usually from the broken bone and lacerated muscles, and 
can be arrested by cold, position, and pressure, and even when a large 
vein has been torn the arrest of the bleeding is seldom difficult ; if pres- 
sure applied methodically at the wound is not sufficient, digital pressure 
over the main artery of the limb will usually enable a clot to form 
promptly. The tourniquet should not be used, because it compresses 
the vein also and thereby favors infiltration of blood and increases the 
probability of gangrene. 

Injury of a large artery is a dangerous complication. It seldom 
happens in an ordinary fracture, except at those points where the artery 
lies very close to the bone, as in the leg. The vessel may be torn across 
by a displaced fragment, or perforated by a splinter, or so bruised or 
pressed upon that its wall sloughs, or it may be opened by the extension 
of the suppuration accompanying necrosis. When the fracture is com- 
pound the profuseness and arterial character of the hemorrhage usually 
leave no doubt as to the nature of the accident, but in simple fractures 
it is not so easily recognized at first. The blood infiltrates the tissues 
of the limb and forms a distinct, fluctuating swelling, at first without 
pulsation or bruit, but at a later period, w r hen a sac has formed by con- 
densation of the parts around it> presenting one or both, a condition 
known as traumatic aneurism, primitive false, or diffuse aneurism, or 
ruptured artery, and usually to be treated according to the principles 
established for that lesion. It has been observed, however, that a 
pulsating tumor formed promptly after fracture will sometimes disappear 
under the moderate pressure of a simple roller bandage ; two such cases 
were reported to the New York Surgical Society in 1879, and Cruveil- 
hier, who had observed the fact several times, found a possible explana- 
tion in a pathological specimen which showed that the rupture of even a 
small artery might give rise to a collection of blood so large as to raise 
the suspicion of injury to the principal artery of the limb. The diagnosis 
may be aided by the presence or absence of pulsation in the distal 
branches of the artery. Verneuil 1 reported a case cured by digital 
pressure upon the main artery, and refers to an oral communication 
from Broca that several cases had been cured by non-operative measures. 

Dupuytren, 2 who was the first to write upon this subject, collected six 
cases of rupture of an artery due to fracture, one of them associated with 
an external wound and frequent hemorrhages. Gurli 3 collected twenty- 
five cases of aneurism and arterial hemorrhage, including Dupuytren's 
list ; and more recently Laurent 4 has reported in full twenty-six cases of 
aneurism, including some of Gurlt's and rejecting others for reasons 

1 Bulletins de la Societe de Chirurgie, 30th March, 1859, vol. ix. p. 402. 

2 Lecons Orales de Clinique Chirur., 2d ed., vol. ii. p. 507, 18b9; being the sub- 
stance of a paper read before the Acad, des Sciences, 24th April, 1825. 

3 Loc. cit., vol. i. p. 526. 

4 Des Anevrysmes compliquant les Fractures. These de Paris, 1874. 



138 COMPLICATIONS OF FRACTURE. 

which do not appear. Of these, 16 followed fracture of the leg, 5 of 
the arm, 2 of the thigh, and 1 each of the forearm, carpus, and a rib. 
Of Gurlt's 25 cases 4 were in the thigh, 20 in the leg, and 1 in the fore- 
arm; 11 were "false traumatic aneurisms," 3 after fracture of the thigh, 
8 of the leg ; and 14 were cases of arterial hemorrhage, most of them 
accompanied by extensive infiltration, and 1 of them (leg) followed by 
the formation of an aneurism. Nepveu 1 collected 53 cases of injury to 
the vessels in fracture of the leg, which he classifies as follows: — 

{ External hemorrhage 14 

Primary accidents, j Collection of blood 2 

20 cases. j Infiltration of blood 1 

[Immediate diffuse aneurism 3 

t . ■ , , ( Consecutive false aneurism 11 

™L!!! ' \ Secondary hemorrhage . 15 

( Gangrene 3 



30 cases. 



The statistics of the treatment employed would be valueless without 
the details of the cases, for in most, of them it was based upon principles 
that have now been abandoned or greatly modified. Mr. Holmes 2 refers 
to " the decided tendency to recovery manifested by wounds of healthy 
arteries when uncomplicated by external injury," and adds : " It seems 
abundantly clear, therefore, that surgical interference in these cases can 
only be justified by the presence of alarming symptoms ; and that by the 
aid of simple position, and, perhaps, in appropriate cases light and even 
compression, a great number of arteries wounded in fracture will heal." 
If an aneurism forms promptly after a simple fracture, it should be 
treated by ligation or compression of the main artery above ; if it forms 
slowly and is not cured by pressure, it may be proper to wait until con- 
solidation of the fracture is well advanced, as also when it is formed at 
a late period by ulceration of the artery, and then to lay it open and tie 
the vessel above and below the opening in it ; this failing, the trunk of 
the artery must be tied above, or the limb amputated. Agnevv 3 says 
amputation is imperative in compound fractures of the thigh complicated 
by laceration of the femoral artery, and in similar injuries of the leg in 
which both tibial arteries are torn. 

Emphysema. — The emphysema which consists in the infiltration of 
atmospheric air through the meshes of the subcutaneous tissue is ob- 
served most commonly after fracture of the ribs complicated by wound 
of the lung, and after fracture of the bones of the face communicating 
with the air-passages, but also occasionally, and to a very limited degree, 
about the wound of a recent compound fracture of a limb. In the first 
case, it is due to the escape of the inspired air through the wound of the 
lung, and its passage, into the wall of the chest under the influence of 
the movements of expiration through the gap created by the fracture. 
It is seldom of any importance, although cases are mentioned in which 
it has spread over most of the surface of the body. If necessary, the 

1 Bull, de la Societe de Chirnrgie, 1875, p. 365. 

2 Syst. of Surgery, Am. ed., vol. ii. p. 384. 

3 The Priucip. and Pract. of Surgery, vol. i. p. 742, 1878. 



COMPLICATIONS OF FRACTURE. 139 

air may be let out through a trocar introduced through the skin at one 
or more points, but it usually undergoes prompt spontaneous absorption. 

The other variety, the emphysema found about a recent wound with 
or without fracture, raises much more serious questions. First described 
by Velpeau, it was attributed by him to the sucking in of the air through 
the wound by the contraction of the muscles, or the movements of the 
segments of the broken limb. It is unquestionable that this may some- 
times be its origin, but it is equally certain that it is much more often 
due to commencing gangrene or acute septicaemia, and the importance of 
the first is as nothing in comparison with the extreme gravity of the 
second, unless it may possibly be regarded as one of the latter, by serv- 
ing to introduce germs capable of exciting putrefaction. The air that 
passes through the lungs into the tissues of the chest-wall is filtered of 
all organic matter in its course through the air-passages, and is thereby 
rendered incapable of producing this effect. As the emphysema of 
gangrene is only a symptom of that complication, and as the process can 
originate without the aid of an external wound, it will be more properly 
spoken of in that connection in the following section. 

Grangrenous Septicemia. (Bronzed erysipelas; acute purulent oede- 
ma ; grave spontaneous emphysema.) — This diversity in the names given 
by different authors to this extremely dangerous complication, not of 
fractures only, but also of many other wounds, is due, not to a corre- 
sponding variety in its symptoms and course, but to different views of 
its nature, or of the importance attributed to different symptoms. I 
prefer the term gangrenous septicemia, because it expresses both the 
general and local conditions, the acute constitutional poisoning which 
kills the patient, and the local change which accompanies and, perhaps, 
causes it. The name bronzed erysipelas given by Velpeau graphically 
indicates the symptoms presented by the skin, but involves a question- 
able etiology; acute purulent oedema and grave emphysema express only 
a single symptom each, the former that of the serous or sero-purulent 
infiltration of the tissues, the latter that of the putrefaction of the same 
liquid. 

The complication is especially common in wounds accompanied by 
much contusion or laceration of the surrounding parts, but may occur 
even when there is no external wound. It begins promptly after the 
accident, usually within a few hours, always within a few days, with a 
swelling about the wound and a change in the color of the corresponding 
skin to a dark hue at the points nearest the wound, and a brow T n or 
brownish-yellow one at the outer border, or over the greater portion of 
the swelling if the latter advances rapidly. The fingers pressed lightly 
upon the surface recognize a fine crepitation due to the presence of gas 
beneath, and the wound, if there be one, discharges a thin, reddish- 
brown liquid of an extremely fetid odor, and containing a few bubbles of 
the same gas, and sometimes pus. If suppuration has fairly begun 
before the occurrence of the complication the flow of pus diminishes, 
giving place more or less completely to the thin liquid mentioned. The 
skin adjoining the wound soon becomes black and gangrenous, and this 
gangrene extends rapidly or may even appear at distant, isolated points. 
The temperature rises, sometimes with a chill, and the pulse quickens ; 



140 COMPLICATIONS OF FRACTURE. 

the patient is conscious, but dull and with an anxious expression, at first, 
and soon becomes unconscious or delirious ; the face is drawn, the eyes 
haggard, the skin and conjunctiva yellow, and death usually occurs on 
the second or third day, with all the symptoms of an overwhelming con- 
stitutional poisoning. If incisions are made in the affected skin they 
give issue to a serum similar to that furnished by the wound, and, if 
carried through the deep fascia, the muscles protrude through them in 
consequence of the tension to which they are subjected. 

The cause of this most grave affection is not entirely understood, but 
its occurrence is certainly favored by the coexistence of an open wound 
in contact with the air, a fact which points to the introduction of the 
poison from without. It is favored also by crushing of the soft parts 
and injury to the nerves, and as it occasionally develops when there is 
no external wound, it seems possible that its cause may sometimes lie in 
altered conditions of nutrition or vitality. 

The common association with an external wound and the success of 
the antiseptic method in the treatment of wounds in general impose upon 
surgeons the obligation to employ this method rigorously in all cases in 
which this complication seems at all likely to ensue, for it is only by 
prevention that we can hope to be of service to the patient. When the 
disease has appeared there is but little chance of saving the limb, or 
even the life. Incisions into the affected parts are worse than useless 
unless they can be combined with the permanent antiseptic bath, for the 
limb is saturated with the liquid, and it is fruitless to try to drain it 
away, and the incisions only furnish additional opportunities for the 
entrance of the poison into the system. Immediate amputation well 
above the affected region offers the only chance, and that but a slender 
one, of saving the patient's life. 

Grangrene. — Excluding the form just described and limiting our atten- 
tion to those due to mechanical causes acting directly upon the tissues 
that become gangrenous, or indirectly through the arteries and veins 
which carry on their blood-supply, we have to consider local gangrene 
limited, at least at first, to the region of the fracture, and total gangrene 
of a larger or smaller segment of the limb. The former is produced in 
fractures by direct violence by the simultaneous crushing of the skin and 
the tissues lying between it and the bone ; in fractures by indirect vio- 
lence it may be produced by the pressure from within outwards of an 
unreduced fragment, or by the compression of the skin between such a 
fragment and the dressings. The latter form is due to the partial or 
complete arrest of the circulation through the principal arteries and 
veins of the limb by changes effected in them by the original causative 
violence (rupture, bruising, perforation), or by their compression against 
the edge of a projecting fragment or under an improperly applied splint. 
The gangrene may be moist or dry ; the latter is due to deficient afflux 
of blood coinciding with a free return circulation, is less likely to spread, 
and is less dangerous to the life of the patient; the former is the more 
common, is frequently associated with obstruction of the venous current, 
and is more likely than the other to spread and give rise to septic 
poisoning. 

As this complication leads not infrequently to suits for malpractice, it 



COMPLICATIONS OF FRACTURE. 141 

is important to know that it is often due to causes beyond the control of 
the surgeon, such as the associated contusion, the pressure of extrava- 
sated blood, injury of the main vessels or nerves, and the occlusion of an 
artery by the pressure of an irreducible fragment. The following two 
cases will serve as illustrations of the last two causes. Many similar 
ones have been recorded. 

1. The wheel of a heavily laden wagon passed across the middle of 
the patient's arm, fracturing the humerus, but leaving no notable exter- 
nal traces. The radial pulse could be felt the next day, and the hand 
could be moved. On the following day sensibility, functions, and circu- 
lation had ceased in the forearm. The limb was amputated above the 
fracture, and its examination showed the brachial artery filled by a firm 
clot at the point corresponding to the passage of the wheel, and for a 
distance equal to its breadth. 1 

2. A lad, seventeen years old, had his femur broken just above the 
knee by the fall of a bale of goods. On the fifth day " the whole foot 
and leg to within three inches of the knee were in a state of complete 
mortification, the parts being tumid, crepitous when pressed, covered 
with dark vesications, cold, and completely insensible." The limb was 
immediately amputated just above the fracture, and its dissection showed 
a perfectly transverse fracture two and a half inches above the loAver 
end of the femur, with the upper fragment dislocated behind the lower 
one, and overriding it three-quarters of an inch. The femoral artery 
and vein were " thrust backward, and tensely drawn across the sharp 
posterior margin of the superior fragment in such a manner that it was 
perfectly obvious that the circulation in both vessels must have been 
completely interrupted." 2 

The young, women, and the old are more exposed to gangrene than 
adult males, and therefore splints and bandages must be used upon them 
with caution, and their effects closely watched. In the old, gangrene is 
more likely to be the result of a contusion than of pressure alone, for 
their atheromatous arteries are easily injured and torn. 

The symptoms vary with the extent and character of the morbid 
process. Localized gangrene caused by the pressure of an unreduced 
fragment may present no symptoms beyond the change in the. portion of 
skin involved, and a slight rise of temperature coinciding with the estab- 
lishment of suppuration and of a communication between the seat of 
fracture and the air ; and gangrene due to arterial obstruction may be 
dry in character, and marked only by the shriveling and blackening of 
the distal portion of the limb. But it is much more common to meet 
with symptoms resembling those of the second case mentioned above ; 
the limb becomes swollen, dark, insensitive, and cold ; bullae containing 
a dark-colored serum appear on the surface, and the edge of the discolora- 
tion is marked by an inflammatory zone, which may in turn become gan- 
grenous, or may suppurate and form the so-called line of demarcation. 
The effect upon the patient's general condition presents all the grada- 

1 Stromeyer, Maximen der Kreigsheilkunst, 1855, p. 92. Quoted by Grurlt, loc. 
cit., i. p. 563. 

2 N. R. Smith., Am. Jouru. Med. Sciences, 1838, vol. xxiii. p. Qti. 



142 COMPLICATIONS OF FRACTURE. 

tions between a slight one and a very severe one resembling that of 
gangrenous septicaemia. 

The treatment, in like manner, varies with the severity of the affec- 
tion. In the circumscribed cases local measures, intended to hasten the 
separation of the slough and to control its putrefaction, are sufficient ; 
when an entire segment of the limb is involved and the process tends to 
self-limitation, to the formation of a line of demarcation, it is well to 
wait until the latter is clearly defined and then to amputate ; but when 
the gangrene is spreading, and a general infection threatens, recourse 
must be had to immediate amputation above the seat of injury. Delay, 
even for a few hours, is dangerous, and the surgeon must have the cour- 
age to urge the immediate sacrifice of the doomed limb as the only 
means of saving the imperiled life. 

Suppuration (simple or phlegmonous); Pywmia ; Necrosis. — Sup- 
puration about a simple fracture is rare, except when due to contusion of 
the overlying soft parts, or to the pressure of a projecting fragment. I 
have met with no instance of it, except after fractures involving joints, 1 
but it is spoken of by most writers as a possible complication of frac- 
ture in weakly patients. The abscess formed by it leads necessarily to 
the transformation of the fracture into a compound one, either by its 
spontaneous opening or by the intervention of the surgeon. 

Acute osteo-myelitis after simple fracture is so rare that it is not 
usually mentioned in the text-books. Spillmann 2 reports a noteworthy case 
that occurred in his own practice. The patient had received a fracture 
of the lower third of the leg, not communicating with the joint, by a 
fall from a height of five feet. When first seen, thirty-six hours after 
the accident, the limb was enormously swollen, very painful, and fluc- 
tuating. Incisions carried through the skin and fascia gave exit to a 
large quantity of pus mixed with drops of fat. The patient died during 
the following night. 

In a case of separation of the upper epiphysis of the humerus quoted 
above (page 52) from Esmarch, suppuration followed, apparently in con- 
sequence of an error in diagnosis which led to two attempts to reduce a 
supposed dislocation. 

Suppuration about a compound fracture, in which primary union of 
the divided soft parts has not been obtained, is almost invariably asso- 
ciated with more or less burrowing of the pus, sometimes with grave 
phlegmonous inflammation of the limb, and occasionally with pyaemia or 
necrosis. These grave accidents, which were frequent and fatal for- 

1 Unless the following case is one : A lad, nine years old, was brought to me with 
the history that nine weeks previously he had fallen heavily upon the left side of his 
chest while skating. No symptoms were noticed at first ; on the third day a hard 
lump formed at the seat of the blow, on the seventh rib a little external to the 
mammary line, and he became feverish and delirious. He was treated first with 
poultices, then with cold, and again with poultices. In six weeks the lump, which 
had been hard, but not very painful or red, opened and discharged pus. The probe 
touched bare bone. I made an incision and removed three necrosed irregular portions 
of bone, one of them being one and a quarter inches long, and having the breadth and 
thickness of the rib. The patient showed no signs of constitutional vice, and the 
history of the case points to suppuration originating, not in a contusion of the soft 
parts, but in the fracture itself. 

2 Diet. Encyclopedique des Sciences Med., 4th series, vol. iv. p. 156. 



COMPLICATION'S OF FRACTURE. 143 

merly, have become rare under antiseptic treatment, and even in hos- 
pitals where ten years ago more than one-fourth of the compound frac- 
tures terminated fatally by pyaemia, this complication is now entirely 
absent for months together. This relative immunity is due to the pre- 
vention of putrefaction and to the thorough drainage of the wound which 
now forms so important a feature of treatment. 

The symptoms of unhealthy or excessive inflammation after compound 
fracture are in general terms as follows : At an earlier or later period 
after the receipt of the injury, usually within the first few days, the 
edges of the wound become swollen, the adjoining skin tense and red, 
the discharge, perhaps, fetid, the patient feverish and uneasy. The 
conditions are aggravated during the following days, the swelling and 
redness extend up the limb, and the surgeon finds points of greater ten- 
derness and hardness, pressure upon which causes pus to flow from the 
wound ; a chill occurs, and the temperature rises to 103° or 104°, the 
tongue becomes dry, the patient is unable to sleep without an opiate, 
and is slightly delirious at times ; the temperature falls in the morning 
and rises in the afternoon, with a regularity that is one of the character- 
istics of hectic fever ; chills occurring at intervals announce the forma- 
tion of metastatic abscesses in the viscera or joints ; pyaemia is established, 
and the patient dies exhausted in a few days or weeks. Meanwhile the 
work of repair seems to be arrested at the wound ; the discharge is pro- 
fuse, thin, reddish, and offensive, and the bone may be seen lying white 
and bare at the bottom of the cavity. 

The treatment will be given in detail in the following chapter. It is 
addressed to the purification and drainage of the wound by the free use 
of antiseptics and by counter-openings at dependent points, to the evacu- 
ation of adjoining abscesses, to the control of the inflammation by poul- 
tices, cold, hot water, irrigation, or baths, and the support of the patient's 
strength by food, stimulants, and medicine. 

Necrosis of splinters has been spoken of in the chapter on repair. 
Necrosis of a portion of one of the principal fragments may occur in a 
compound fracture as the result of the stripping off of the periosteum, 
and of the destruction of the corresponding portion of the marrow by 
crushing or sloughing. The compact tissue being thus deprived of its 
blood-supply by the rupture of the vessels which come to it from the peri- 
osteum and the destruction of those coming from the marrow, dies, and 
is slowly separated from the portion that remains alive by the formation 
of a line of demarcation at their junction, as shown in fig. 75. The 
dead piece may lie loose in the cavity of the wound, or may be envel- 
oped more or less completely by the callus, which is continuous with the 
lining portion of the shaft through new bone formed on the under side of 
the loosened periosteum (fig. 76). A few cases are on record in which 
a long piece, 6J and 7 inches in two cases, comprising the entire thick- 
ness of the shaft, had died and been removed after some weeks by the 
surgeon. 

The small pieces of bone which are so frequently cast off during the 
healing of a compound fracture are composed sometimes of splinters and 
sometimes of portions of the callus which have died in consequence of 
the excessive activity of the productive osteitis. The continued deposi- 



144 



COMPLICATIONS OF FRACTURE. 



tion of bone narrows the canaiiculi until they become no longer pervious, 
and the part dies through lack of blood. It is an irregular and objection- 
able manifestation of the effort made by nature to remove an excessive 
and unnecessary amount of tissue. 



Fig. 75. 



Fis. 71 





Necrosis of the end of a long fragment 
after prolonged suppuration. 



Necrosis after fracture of the shaft of the 
femur, with enveloping callus, a. Tin 
sequestrum. (Gurlt.) 



The presence of a necrosed fragment is shown by the persistence of a 
sinus, at the bottom of which a bare and sometimes movable piece of 
bone can be felt with the probe. The treatment consists in the enlarge- 
ment of the opening by the knife or compressed sponge, and the removal 
of the fragment. If necessary, the involucrum or the obstructing por- 
tion of the callus must be cut away. Sometimes the wound closes and 
the fragment makes its presence known only after the lapse of months 
or years. 

Muscular Twitchings and Tetanus. — Involuntary twitchings of the 
muscles of the injured limb are not uncommon in the first week follow- 
ing the injury. They are most likely to occur at night, just as the 
patient falls asleep, and cause pain by the movements they communicate 
to the broken bones. Sometimes the pain is not so disturbing to the 
patient as the feeling of indefinite* dread which may accompany the 
twitchings, and in this respect, as in others, they resemble the similar 
phenomena observed after amputations and excisions. They are relieved 
or prevented by solid support of the limb, reduction of displacement, and 
a well-adjusted splint or immovable dressing. They rarely continue 
beyond the first week, but in a few cases have merged gradually into 
tetanus. 



COMPLICATIONS OF FRACTURE. 145 

Tetanus is not a common complication of fracture. Poland 1 found that 
in thirty-two years, 1825 to 1857, at Guy's Hospital it had occurred 
sixteen times after compound and once after simple fracture, and it is 
worthy of note that seven of these cases were lacerations and fractures 
of the fingers or hands, and one of the toes. The statistics of Lawrie 
and Peat quoted by Gurlt (loc. cit., p. 554) give four cases after simple 
fracture and seven' after compound ; while of twenty reported cases col- 
lected by Poland and analyzed by Gurlt, one was after simple and nine- 
teen after compound fracture, and in seven others there was simple 
fracture associated with lacerated w T ounds. 

Some autopsies have indicated as a probable cause injury to, or pres- 
sure upon, a large nerve by one of the fragments ; in other cases the 
cause appears to be the same as in wounds that are not associated w r ith 
fracture. Poland calls attention to the fact that in a number of cases 
the exposure of the patient to a sudden change of temperature seemed 
to have been the immediate exciting cause. 

Treatment holds out but a slight prospect of success. If it is known 
or suspected that a fragment is pressing on a nerve the pressure must be 
relieved. Other measures are those recommended when the affection 
complicates other wounds, and for them the reader is referred to works 
on General Surgery. Occasional successes have been obtained by the 
administration of chloral in large doses, Calabar bean, the inhalation of 
chloroform, and the division or stretching of the nerve supplying the 
region of the wound. Gurlt recommends prolonged diaphoresis, main- 
tained by hot air or vapor, in cases where chilling appears to have been 
the cause. 

Delirium Tremens and Nervous Delirium.— Nervous delirium, or trau- 
matic delirium, as it was at first called by Dupuytren, who was the first 
to describe it, resembles delirium tremens so closely that the diagnosis 
between them is not always easy to make. It presents all the symptoms 
of delirium tremens except the tremor of the limbs. There is the same 
sleeplessness, fixed delusion, loss of appetite, and insensibility to pain. 
Both occur after slight as well as after severe injuries, and as delirium 
tremens attacks habitual drinkers who are not drunkards as well as those 
who drink to excess, the differential diagnosis cannot always be guided 
by the scanty information obtainable concerning the patient's habits. 
Fortunately this is not of much practical importance, for the treatment 
is the same. 

Usually one or two sleepless nights give warning of an approaching 
attack, and if this warning is heeded, if sleep is secured by morphine or 
chloral, the bowels moved by a brisk purge, and the strength supported 
by a nutritious and easily digestible diet, the attack may be averted or 
its severity diminished. When the disease has fairly set in it must be 
treated according to the method that commends itself to the choice of 
the surgeon. These methods are numerous and differ widely ; the reader 
is referred to formal articles upon the subject. It may be said, how- 
ever, that the indications are to procure sleep, to support the strength, 



10 



Guy's Hospital Reports, 1857, p. 1. 



146 REMOTE CONSEQUENCES OF FRACTURE. 

and especially to avoid excitement and muscular action. The patient 
should be controlled not by mechanical means, such as a strait jacket 
or tying him in bed, but by the will and tact of an attendant. Holmes 
and Bryant both recommend morphine to be given subcutaneously in 
half-grain doses, a diet of beef-tea, milk, and eggs, and the avoidance of 
stimulants. 

The remote consequences or complications remaining to be considered 
are exuberant and painful callus, paralysis by injury to or inclusion of 
a nerve and secondary fracture. Failure of union and vicious union 
will be considered in separate chapters. 

Exuberant and Painful Callus. — Excessive size of the callus, common 
in the earlier stages of repair and sometimes persistent, does not require 
surgical attention unless it interferes with the functions or nutrition of 
the limb, or is due to the presence of a sequestrum or splinter or to dis 
ease of the callus itself. A different opinion was held T^y the earlier 
surgeons who sought to remedy it by diet, astringent applications to the 
surface, and compression, and, these failing, by excision of a portion. 
According to Malgaigne, it is found most frequently after fracture of the 
femur below the trochanters, and is then probably due to unreduced 
displacement of the fragments. A sudden increase in size, accompanied 
by angular or longitudinal displacement, has been observed not infre- 
quently after premature use of the limb. One of the best known cases 
is that of Weinhold of Halle, quoted by Malgaigne and most subsequent 
writers. 

The patient, a lad of 18 years, began to walk four weeks after he had 
fractured his thigh in the middle third. Six w T eeks later the limb pre- 
sented a shortening of two inches, and the callus had become enormous, 
measuring eighteen and a half inches in circumference; the surrounding 
tissue was engorged, and there were fistulous abscesses at various points. 
Extension with pulleys failing to reduce the displacement, Weinhold 
drilled into the callus an inch on the outer side of the femoral artery 
with the intention of passing a seton so as to soften it. He encountered 
in its centre a cavity four inches in diameter, passed the drill through 
and out upon the other side, and followed it with the seton. Free sup- 
puration ensued and led by the fifth week to the resolution of the en- 
gorgement of the soft parts and the closing of the fistulae ; the callus 
softened until it yielded under the pressure of the finger, and then Wein- 
hold renewed the extension with such success that by the tenth week 
there remained a shortening of only two lines. The seton was retained 
a fortnight longer, and a few weeks later the patient was able to walk 
without crutches, the thigh had regained its natural size, and the wounds 
had closed. 

In other cases, especially after gunshot fracture, the excessive forma- 
tion of callus is due to the presence of a splinter or sequestrum. These 
cases are usually marked by persistent suppuration, but it sometimes 
happens that the fistula closes and the patient remains apparently well for 
months, and even years, until, without known cause, or under the influence 
of fatigue, traumatism, or chilling, the part becomes painful and swollen, 
and an abscess forms. A number of such cases are contained in a thesis 



REMOTE CONSEQUENCES OF FRACTURE. 147 

by Tisserand, 1 of which I reproduce the following, one of splinter, the 
other of necrosis. 

Richet was called, in 1863, to see a gentleman who, seven years before, 
had broken his leg. The fracture had united after some delay, and the 
patient had resumed his usual occupations. Without known cause other 
than fatigue, the limb had suddenly become extremely painful and much 
swollen at the seat'of the old fracture. Richet thought he found deep fluc- 
tuation, and made a free incision down to the bone, but without encoun- 
tering pus ; he then forced a director into the bone, which proved to be 
a mere shell, and a gush of thick pus followed. He found within the 
cavity and removed a smooth splinter as large as the little finger. The 
wound healed promptly, and the patient had remained well up to the 
time of the last report, sixteen years afterwards. 

In 1868 the same surgeon treated a compound fracture of the leg ; at 
the end of four months consolidation appeared to be perfect. Eighteen 
months afterwards an abscess formed at the seat of fracture, bare bone 
was felt, and Richet cut down upon and removed the necrosed but still 
adherent end of one of the fragments. The patient made a complete re- 
covery. 

In a few cases an abscess has formed within the bone at the seat of 
fracture and presented the symptoms and appearances characteristic of 
the central, abscesses which are found in or near the expanded ends of 
the long bones, especially the tibia, during or just after adolescence, 
and without containing any sequestrum. One such case was reported 
by Despr&s ; 2 a man of 26, with an abscess within the tibia at the junction 
of the upper and middle thirds nine years after a fracture of the same 
bone just above the ankle. Pain had been felt about once every six 
months since fracture, and had been persistent for the five months pre- 
ceding his admission to the hospital. The case is not so demonstrative 
as I should like, for the abscess was too far removed from the seat of 
the fracture, and the patient's age was such that its formation may have 
been only a coincidence. More positive cases are contained in a thesis 
on abscesses in bone, published in Paris, if my memory serves me, by 
Ed. Cruveilhier, about 1863, but unfortunately I am unable to verify 
my recollection. The diagnosis in this class of cases is made by atten- 
tion to the recurrence of pain and swelling at the same point; the treat- 
ment is to evacuate the abscess by applying a trephine at the point where 
the maximum of pain on pressure is found. 

In addition to the cases in which the pain is certainly due to an in- 
flammatory process there are others in which pain, sometimes so severe 
as to lead to amputation, accompanies and follows regular repair without 
recognizable cause, and certainly not due to inflammation of the callus 
or bone. In some cases it has been caused by injury to, or pressure upon, 
a nerve by the edge of a fragment or the callus, and in still others it has 
been attributed to the strangulation of a nerve, within the callus. This 
complication has been made the subject of an excellent thesis by Pastu- 
raud, 3 and has been studied especially by Gosselin in his Clinique Chi- 

1 Des Abces intra-osseux consecutifs aux Fractures. These de Paris, 1879, No. 524. 

2 Bulletins de la Societe de Chirurgie, 1877, p. 584. 

3 Etude sur les Cals douloureux. These de Paris, 1875, No. 70. 



148 REMOTE CONSEQUENCES OF FRACTURE. 

rurgicale de la Charite, and the article Osteite of the Nouveau Diction- 
naire de Medecineet Chirurgie Pratiques. The latter author attributes 
the pain in the earlier periods to a non-suppurative osteitis within the 
callus, and in the later stages to an osteo-neuralgia, of which, however, 
he says he can give no explanation. Pasturaud explains it by the sup- 
position of injury to nerve filaments or nerve trunks at the time of the 
accident, an injury which results in a progressive neuritis similar to that 
observed occasionally after injuries of the soft parts alone. He supports 
his argument by a few clinical facts and by copious quotations from Dr. 
Weir Mitchell's valuable work on Injuries of the Nerves. 

The pain is usually severe, almost continuous, and increased at night. 
In a case of fracture of the leg reported by Nicod, in 1818, the suffer- 
ing increased so steadily as consolidation advanced that the patient died 
exhausted by it. In other cases it is intermittent, recurring after slight 
shocks, or movements, or even spontaneously, or after a change in the 
weather. Motor or sensory changes, paresis, hyperesthesia, or anaes- 
thesia in the limb below the fracture indicate division of and injury to a 
large nerve, as in the cases quoted below in this and the two following 
sections. Local alterations of nutrition are produced by the same cause, 
and may appear as ulcerations of the skin, atrophy of the limb, or, more 
commonly, as delay in consolidation. 

In the cases of pure neuralgia, that is, of pain without motor or sen- 
sory changes, the treatment is that of other neuralgias, and in some of 
the reported cases a complete cure has been effected by repeated blister- 
ing. In one case (Dr. Hayes Agnew, quoted by Dr. Weir Mitchell, loc. 
cit., p. 295) it was considered necessary to excise two and a half inches 
of the ulnar nerve just above the elbow ; the recovery of motion was 
almost perfect, and of sensation very great. In another, of intense 
neuralgia following a blow upon the region of the epitrochlea, Denucd 1 
cut clown upon the ulnar nerve, found it pressed upon by the displaced 
epitrochlea, excised tbp projecting part of the bone, and cured the 
patient. 

In the cases in which the associated symptoms point to inclusion of a 
large nerve in the callus, or its irritation by the bone or callus, an ope- 
ration may be undertaken for the removal of the cause. Such opera- 
tions have been successful in some cases and have failed in others. 
Thus, Prof. Trelat 2 was called to treat a child eight years old, who had 
received a fracture of the humerus in the lower third, which had united 
with much overriding of the fragments and an exuberant callus. There 
was paralysis of the extensor muscles of the forearm, a point of extreme 
tenderness on pressure corresponding to the outer and lower edge of the 
upper fragment, and hyperaesthesia of the outer surface of the forearm. 
After a long and careful search Trelat found the cutaneous branch of the 
musculo-spiral nerve imbedded in dense cellular tissue and resting upon 
the edge of the upper fragment. It had at this point the appearance of 
a ganglion, or rather of a plexus of nerves, tightly^bound together by 
fibrous tissue ; he dissected it free and excised the projecting part of the 
bone. The operation relieved the pain, but the paralysis persisted ; 

1 Diet, de Medecine et Chirurgie Pratiques, art. Conde, p. 721. 

2 Pasturaud, loc. cit., p. 49. 



REMOTE CONSEQUENCES OF FRACTURE. 149 

electricity was used until the date of the report a year later, and at that 
time the patient had not entirely regained the use of the wrist. 

In a case 1 of fracture of the forearm, in which the median nerve was 
pressed upon by the lower fragment, Prof. Hamilton excised the promi- 
nent portion of the bone, but without success. A year after the opera- 
tion the muscles of the hand and forearm were completely paralyzed, 
and from time to time very painful. 

An exuberant callus, especially if associated w T ith displacement of the 
fragments, may give trouble by pressure upon nerves and bloodvessels, 
which will require an operation for its relief. Delens 2 reports a case in 
which an exuberant callus after fracture of the clavicle caused complete 
disability of the arm by pressure upon the brachial plexus and subcla- 
vian artery. It was entirely relieved by resection. He refers to a 
case in which Vogt resected the upper end of the humerus, after frac- 
ture at the surgical neck with pseudarthrosis and exuberant callus, to 
relieve loss of power and sensation due to pressure upon the nerves. 

Paralysis due to Injury of a Nerve. — Division, laceration, or contu- 
sion of a large nerve by the broken bone, at the moment of the fracture, 
is not a common complication, but still it has been observed in connec- 
tion with fractures of all the principal bones of the limbs, the clavicle, 
and the pelvis. It is most common in the arm after fracture of the 
humerus in its middle third, or of the internal condyle, the musculo- 
spiral being involved in the former case, the ulnar in the latter. A 
number of interesting cases are given briefly by Dr. Weir Mitchell, 3 
together with references to the principal papers on the subject, the most 
complete of which are those by Ferreol-Reuiilet 4 and Callender. 5 

In a case reported by Berger, 6 occurring in the service of Prof. Gos- 
selin, the nature of the lesion was verified by autopsy. The fracture 
was at the surgical neck of the right humerus, and the symptoms were 
paralysis of the muscles supplied by the musculo-spiral nerve, anaesthe- 
sia of the back of the arm, back, and outer side of the forearm, of the 
outer two-thirds of the hand, and of the first three fingers. The patient 
died of intercurrent scarlet fever, and the autopsy showed the lower 
fragment displaced upwards and inwards, and the musculo-spiral nerve 
stretched across its edge. The nerve was reduced two-thirds in size for 
the distance of an inch, and showed a great excess of fibrous tissue with 
destruction of the nerve-tubes. 

The only case of this class, exclusive of gunshot fractures, which 
came under Dr. Mitchell's observation, was one in which the sciatic 
nerve was bruised at its point of emergence from the sciatic notch by a 
fracture of the pelvis, occasioned by a fall from i height of forty feet. 
Intense neuralgia followed and was relieved by blistering. The patient 
made a complete recovery. 

The symptoms, course, and result vary with the function of the nerve 

1 Quoted by Pasturaud, p. 47. 

2 Archives generales de Medecine, Aug. 1881, p. 170. 

3 Injuries of Nerves, p. 104. 

4 Etude sur les Paralysies du membre superieur liees anx Fractures de l'Humerus, 
Paris, 1869. 

5 St. Bartholomew's Hospital Reports, vol. vi. 1870. 

6 Bulletins de la Societe Anatomique, Juillet, 1871. 



150 REMOTE COX SEQUENCES OF FRACTURE. 

and the degree of the injury. Except after complete division, or when 
the pressure upon the nerve is permanent, recovery under appropriate 
treatment (for which the reader must be referred to special works) 
appears to be the rule. 

Paralysis by -Inclusion of a Nerve in the Callus. — A few cases have 
been reported in which paralysis of one or more groups of muscles has 
been'causecl by the pressure of the callus upon a main nerve-trunk in- 
cluded within it. This accident happens only when the nerve lies close 
to the bone at or near the point of fracture, as in the case of the mus- 
culo-spiral nerve in fractures of the shaft of the humerus. The symp- 
toms are loss of power and of sensibility, if the nerve is a mixed one, 
noticed usually on the removal of the dressings towards the end of the 
period of repair. Electrical stimulation of the nerve above the callus 
produces no effect upon the muscles, and the latter lose also their power 
of reaction to electrical currents applied directly to them. The lesion 
lies in the compression of the nerve by a fragment or by the continuous 
deposit of bone around it. It lies in a groove or tube, the calibre of 
which steadily diminishes by progressive deposit of bone upon its sur- 
face, just as the vascular canals of new or inflamed bone diminish in 
productive or condensing osteitis ; but as all attempts made to produce 
this condition experimentally have failed, we must believe that the ten- 
dency to this filling up of the channel or tube in which the nerve lies is 
slight. Probably an associated neuritis is required to effect the result, 
one due, not to the strangulation of the nerve, but to antecedent bruis- 
ing. The treatment consists in the liberation of the nerve and its sub- 
sequent stimulation by the interrupted or, better, the constant current. 
The following case illustrates the prominent features, and is the first in 
which an operation was done to relieve the disability. 

L, 1 22 years old, received a compound fracture of the right humerus 
at the junction of the lower two-fifths and the upper three-fifths, with 
projection of the lower fragment. The limb was placed in a starch 
apparatus and kept there for forty days. During the first few days the 
patient complained of sharp lancinating pain at the seat of the fracture. 
On removal of the apparatus complete paralysis of the extensor muscles 
of the hand was discovered. 

Four months after the accident he consulted Oilier, who found the 
bone firmly united with a slight increase in its size at the seat of frac- 
ture, and with inequalities behind that were easily recognizable by the 
finger. The forearm was atrophied, and there was complete paralysis of 
the extensors and of all the muscles of the forearm supplied by the 
musculo-spinal nerve. No electrical reaction in these muscles, notable 
diminution of sensibility in the thumb and forefinger. Pressure over 
the course of the nerve just below the callus caused vague sensations in 
the posterior portion of the forearm. 

After using electricity for two months without any gain M. Oilier 
made an incision three inches long in the course of the nerve at the level 
of the callus, and on dissection found a branch of the nerve which he 
traced back into the callus. He then cutoff a portion of the callus care- 

' Oilier. Traite de la Regeneration des On, vol. ii. p. 414. 



REMOTE CONSEQUENCES OF FRACTURE. 



151 



fully with a chisel and exposed a closed canal in it in which was found 
the nerve ; the canal was then laid open upwards and downwards for a 
distance of two inches, and the nerve liberated. It was compressed at 
one point to a diameter of J-th inch by a spicula of bone, apparently a 
portion of the lower fragment, and enlarged above it to a diameter of 
nearly half an inch ; below the compressed part the size was normal. 
The spicula was cut away, the nerve loosened from the underlying bone, 
the adjoining periosteum removed, and the wound closed. The paralysis 
of sensation and motion gradually disappeared, and the patient was 
completely cured. 

In another case reported by Delens, 1 the same paralysis was observed 
after fracture of the humerus in the lower third, a few days after the 
removal of a plaster splint which had been applied immediately after the 
accident and kept on for forty days. At the ope- 
ration the nerve was found lodged in a bony 
groove of new formation, flattened, and incrusted 
with spicule, also of new formation. It was 
liberated, and the wound closed. Within a 
week the power of voluntary motion had been 
partly recovered, but afterwards, under the in- 
fluence of a diffuse phlegmon of the other arm 
originating in a vaccination pustule, it was again 
lost, and was only regained imperfectly. 

Secondary Fracture. — It occasonally hap- 
pens that after a fracture has united and the 
patient has begun to use the limb again, or has 
even used it for some time, the callus or the bone 
breaks again at the same point. It has been 
shown that the callus is composed of a more or 
less bulky mass of spongy bone, which requires 
considerable time to acquire its full strength 
and to become firmly united with the principal 
fragments. During its evolution, therefore, it 
is liable to be broken or separated from the 
fragments by the action of any such force as 
may cause a fracture in a normal bone, and the 
shorter the period that has elapsed since the original accident the greater 
is this liability. Furthermore, if the fragments are so displaced that 
they give each other but little support and the strength of the union 
depends solely upon the solidity of the callus, this liability to fracture 
is still further increased. Consequently, we find secondary fracture 
occurs in the great majority of cases soon after the splints have been re- 
moved and the patient begins to use his limb, and especially after frac- 
tures of the shaft of long bones that have united with much displacement. 
It is rare, if not unknown, after fracture of the short spongy bones or of 
the expanded extremities of the long ones. It may be complete or in- 
complete, resembling in the latter case the infraction or bending described 
in Chapter II. It is produced by the same causes as an ordinary frac- 




Ollier's case of inclusion of 
the musuclo-spii 
the callus. 



nerve 



1 Bulletins de la Societe de Chirurgie, 1880, p. 26: 



152 REMOTE CONSEQUENCES OF FRACTURE. 

ture, by muscular action, or even, in the lower extremity, the weight of 
tlfe body in walking. 

Experiments were made by Jacquemin 1 to determine the amount of 
force necessary to produce a secondary fracture. He took the femur of 
a man who died of pneumonia forty-five days after its fracture, cleaned 
it, and fixed it upon a table with the callus and long fragment projecting 
beyond the edge, and attached weights to the projecting end. 62 pounds 
caused the callus to bend without apparent rupture ; Q6 pounds caused 
complete separation, the callus remaining attached to the upper fragment. 
An oblique fracture of the humerus treated in the same manner after death 
on the fifty- ninth day bent and broke under a weight of less than 62 pounds. 

The periods at which secondary fracture has been observed vary from 
a few days or weeks to several years ; in the latter cases the violence 
that produces it is usually such as would be thought sufficient to cause 
fracture of the bone in its normal state. In exceptional cases repeated 
fracture occurs after slight causes, and is then to be attributed to defec- 
tive formation of the callus. In 87 cases analyzed by Gurlt, it occurred 
20 times in the femur, 11 times in the leg, 3 times in the forearm, twice 
in the arm, and once in the clavicle; in 2 (femur and leg) it occurred 
twice, and in 1 (femur) three times. In 3 cases the secondary fracture 
was incomplete (infraction), at intervals of 13 weeks, 133 days, and about 
6 months ; the patients being 19, 16, and 13 years of age respectively. 

The symptoms are the usual ones of fracture : mobility and crepita- 
tion ; or, in the case of infraction, deformity by the production of an 
angle at the point of fracture. The treatment is the same as for an 
ordinary fracture: reduction and contention for the complete ; reduction, 
rapid or gradual, and contention for the incomplete. Advantage, when- 
ever it is necessary and possible, must be taken of the accident, to over- 
come any previous displacement that may have favored the production 
of the second fracture. In fractures that recur more than once, shorten- 
ing, often to a considerable extent, is to be expected. Gosseiin 2 reports 
a case of a man of 25, who broke his femur six times in the course of 
twenty months. The fractures did not occur when he began to Walk, 
but from the eighth to the fifteenth day thereafter, and generally in con- 
sequence of a slight effort, either to save himself from falling or to run, 
and once while dancing. Each time the patient had been allowed to get 
up on the forty-fifth day. Gosseiin saw him after the last fracture, kept 
an apparatus on for two months, and the patient in bed for three months. 
There was permanent shortening of 2J inches. 

In three other cases observed by the same surgeon secondary frac- 
ture occurred in young men who, in disobedience of instructions, left 
their beds and attempted to walk at about the fiftieth day. The prac- 
tical conclusion is that after fractures of the femur patients should not 
be allowed to use the limb, even with crutches, until the seventieth or 
seventy-fifth day, notwithstanding apparent firmness of the union, and 
that splints should be kept for the same length of time upon patients 
whose obedience and reasonableness cannot be counted upon. 

1 These inaugurale, Paris. 1822, quoted by Malgaigne. 

2 Clinique Chirurgicale de l'Hopital de la Charite, vol. i. p. 389. 



TREATMENT OF FRACTURES. 153 



CHAPTER VIII. 

TREATMENT OF FRACTURES. 

The treatment of a fracture, strictly speaking, begins immediately 
after the accident that has caused it. Unfortunately for the patient, the 
first attentions are usually given, and his removal to his home or to the 
hospital carried out, by bystanders who do not fully appreciate the ex- 
tent to which the injury already received may be aggravated by their 
well-meant but sometimes ill-judged interference. Or the patient him- 
self, moved by a natural but equally harmful impulse to convince himself 
that he has not been seriously hurt, attempts to use his injured limb, and 
thus increases the displacement and the laceration. It is of great im- 
portance that this aggravation of the injury by unnecessary movements 
of the limb should be avoided ; it is most liable to occur when the frac- 
ture involves the lower limb, and under such circumstances the patient 
should not be moved except upon a stretcher, and preferably after the 
application of a temporary splint. When a bone of the arm or forearm 
is broken sufficient immobility is obtained by supporting the limb with 
the other hand or in a sling. 

Afer the clothing has been removed and the diagnosis made, the 
patient should be placed, if the fracture is of the lower extremity, upon 
a narrow bed furnished with a mattress and springs, nob soft enough 
to yield noticeably under the weight of the body. If necessary, the 
firmness of the bed may be increased by placing planks lengthwise under 
the mattress. In cases of severe compound fracture of the femur it may 
be desirable to use a "fracture bed," of which there are many varieties 
in the market, designed to allow the bedding to be changed, the natural 
wants of the patient attended to, and the wound dressed without change 
of position. A simple arrangement which will meet the indications suf- 
ficiently well can be readily made with the aid of a carpenter. A stout 
rectangular frame, three feet wide and a little longer than the patient, 
is made and fitted with metal buttons or hooks at intervals of a few 
inches along the outer surface of its two sides, to which strips of stout 
cotton cloth six or eight inches wide can be attached by eyelets or cords. 
Two ropes, each about nine feet long, fastened by their ends to the four 
corners of the frame, complete the arrangement. The frame is placed 
upon the bed, and the patient upon it ; when it is desired to raise him 
from the bed the slack of the tw r o ropes is engaged in the hook of a pul- 
ley, the mate of which is attached to the ceiling immediately above the 
centre of the bed or to a frame constructed for the purpose. If the 
bands lying under the pelvis and upper portion of the thigh have been 
previously removed, the bed-pan can be conveniently used. The strips 



151 TREATMENT OF FRACTURES. 

can be changed by attaching a fresh one to the end of the one it is to 
replace, and drawing both through. 

In the usual run of cases a bed-pan can be used without giving pain 
to the patient or disturbing the process of repair, and I have never found 
it necessary to use a device which, I fancy, is more frequently recom- 
mended than employed ; that of cutting a hole in the centre of the mat- 
tress and lining it with some water-proof material. Sheets may be 
changed by folding half of the fresh one longitudinally, turning the pa- 
tient slightly upon one side, placing the folded portion under him, turning 
him then upon the other side, and drawing the fold through ; or by attach- 
ing the end of the fresh sheet to the upper end of the soiled one and work- 
ing both down gradually to the foot of the bed, while first the shoulders 
and then the hips of the patient are slightly raised to aid the process. 

Bed-sores are best guarded against by keeping the bed-clothing 
smooth and the skin dry, bathing exposed points occasionally with alco- 
hol, camphor spirits, vinegar, or ether, mixed with twice the quantity of 
water, and by using inflated rubber rings under the pelvis. If they 
become imminent the affected surface should be painted with a thick 
coating of flexible collodion, and every effort made to protect it from 
pressure. If they occur they must be treated, according to circum- 
stances, with emollient or stimulating dressings. When not otherwise 
contra-indicated the water-bed may be used with great advantage. Bry- 
ant says he has found a mattress divided into three parts, and a water 
cushion substituted for the middle section, of great use. 

The aim of treatment is to secure prompt and firm union with the 
minimum of deformity and disability. It comprises two main indica- 
tions : 1st, to reduce the displacement, to "set*' the fracture ; 2d, to main- 
tain this reduction ; and, while both these indications can sometimes be 
met with much ease, there are other occasions on which the former is im- 
possible or the latter taxes the professional and mechanical skill of the 
surgeon to the utmost. 

By the reduction or setting of a fracture is meant the restoration of 
the fragments to their normal positions and the consequent removal of 
such displacements as may exist. As most fractures of the limbs are 
accompanied by shortening, reduction is usually effected by traction,, or, 
speaking technically, by extension and counter-extension, aided, when 
necessary, by lateral pressure to bring the fragments into line, coaptation, 
and by rotation to correct rotatory displacement. When angular dis- 
placement alone exists, as in incomplete fracture, lateral pressure upon 
the angle with the thumbs, while counter-pressure is made by the fingers 
grasping the limb above and below, is the means usually employed ; and 
in longitudinal displacement with separation, as after fracture of the pa- 
tella, the downward traction is made of course upon the upper fragment. 

Usually considerable force must be exerted to overcome the contrac- 
tion of the muscles which has followed or produced the displacement, 
but the amount of this force and its effectiveness vary within wide limits. 
The older surgeons found in the spasm of the muscles provoked by the 
traumatism, and in the acute inflammatory processes of the first stage, an 
argument for postponing all attempts to reduce the fracture until after 
the spasm and the inflammation had yielded to antiphlogistic treatment 



TREATMENT OF FRACTURES. 155 

and rest, but it is now well understood that the best means of subduing 
the one and preventing the other is be found in the early reduction of 
the displacement and the prevention of its return, and the general rule 
of treatment now is to set the limb at the earliest possible opportunity, 
usually at the first visit, whether it be immediately after the accident or 
only after the lapse of several days, using an anaesthetic, if necessary, 
to overcome the resistance of the muscles. The exceptions to the rule do 
not annul it entirely in the cases to which they apply, but only limit the 
degree to which it should be carried out. They are found in exagger- 
ated muscular spasm and in acute painful inflammation of such an extent 
as to prevent the application of a retentive apparatus sufficient to main- 
tain the reduction. The rule is positive to make as much reduction as 
can be made without using extreme force and as can be maintained with- 
out dangerous pressure upon the limb. It is a rule which is radically 
incompatible with routine practice and requires the best judgment and 
tact of the surgeon ; its guiding principles are : 1st, that reduction, to 
any extent, diminishes pro tanto the irritation and reaction due to the 
fracture ; 2d, that excessive force employed to accomplish reduction may 
cause additional lesions, the consequences of which are worse than those 
of displacement ; and 3d, that more or less complete reduction is still 
possible one, two, or three weeks after the receipt of the injury, that is, 
at a time when two important obstacles to reduction, spasm and inflam- 
mation, have ceased. 

The objection to the employment of extreme force lies in the danger 
of thereby rupturing an important vessel in case the resistance should be 
due to some mechanical cause, or of causing persistent pain, convulsions, 
or even tetanus if it is due to muscular spasm. Cases of death caused 
in both these manners are on record. Severe inflammation is a contra- 
indication to the use of force for two reasons : by involving the muscles 
it diminishes their extensibility greatly and thus opposes a mechanical 
obstacle that cannot be overcome without rupture of the stiffened fibres ; 
and the exudation that accompanies it increases the bulk of the limb to 
such an extent that its forcible elongation results necessarily in a great 
increase of the tension under the enveloping fascia. The rupture of the 
muscular fibres adds to the existing traumatism and increases the chance 
of suppuration ; and the tension may become so great as to cause gan- 
grene by interference with the circulation. These are the dangers to 
be avoided and especially to be borne in mind when the use of an anaes- 
thetic deprives the surgeon of the warning that w r ould otherwise be given 
by the pain occasioned by the traction. 

Ordinary muscular spasm can be annulled by ether or opium, but if 
the former is used care must be taken to prevent violent movements of 
the limb during the stage of excitement. In a case of fracture of the 
leg Broca overcame the spasm very cleverly by compressing the femoral 
artery for a few moments. The spasm, which had been so violent and 
painful that it was impossible to handle the limb, disappeared immedi- 
ately ; the limb was placed in an apparatus, and the spasm did not return 
until the dressing was changed. Pressure was then again made with the 
same success. This method promises sufficiently well to justify its use 
in some cases before recourse is had to anaesthetics ; it enabled me to 



156 TREATMENT OF FRACTURES. 

reduce a fracture of the leg that would not yield to traction by the hands. 
Gradual, continuous extension by India-rubber, or by a weight and pul- 
ley, may be trusted to overcome any pure muscular spasm when it can 
be employed, but it is applicable only to cases where the seat of the 
fracture is sufficiently high upon the limb to allow the proper attach- 
ment of the bands. Spillmann 1 recommends as of occasional service the 
internal administration of atropia with a view to reduce the spasm, or 
the local use of an ointment containing belladonna and mercury when 
the spasm is associated with inflammation. 

Inflammation is to be treated by reduction of the displacement, so far 
as possible, and by poultices. If it advances to suppuration the pus 
must be promptly evacuated and the fracture then treated as a com- 
pound one (q. v.). While waiting for the proper time to make complete 
reduction the limb must be immobilized by temporary dressings, with the 
fragments in the best attainable position, by the aid of fracture-boxes, 
cushions, inclined planes, or temporary splints. 

Reduction is made, as has been said, by extension, counter extension, 
and coaptation ; the first two, acting together, are intended to restore 
the limb to its original length by drawing the fragments past each other ; 
the third is exerted transversely to bring them into line. There has 
been much discussion in the past concerning the position in which the 
limb should be held while reduction is made, some preferring extension, 
others flexion. Since the introduction of anaesthetics the question has 
lost much of its interest, but the fact remains that ordinarily the muscu- 
lar resistance is less when the limb is partly flexed than when it is fully 
extended, and, therefore, that this position should be chosen whenever 
any important resistance is offered by the muscles. Practically, it is 
desirable that the limb during reduction should be in the position it is to 
occupy during treatment, in order to avoid the risk of reproducing the 
displacement during the change that would otherwise be necessary. 
Most fractures of the arm and forearm are reduced and treated with 
the elbow flexed, those of the femur with the knee extended, and those 
of the leg with the knee extended or slightly flexed. 

Extension is best made by traction with the hands applied to the lower 
end of the broken bone, or to the distal segment of the limb if the 
fragment is too small to be readily grasped or if the limb is too tender. 
Counter-extension is made at similar distances from the seat of fracture 
by the hands of another aid, or by bands made fast to a neighboring 
fixed point. The surgeon meanwhile applies his own hands to the seat 
of fracture to appreciate the movement of the fragments, and to make 
coaptation at the proper moment. These general rules are, however, 
subject to many exceptions depending on the character of the displace- 
ment and the difficulties of the reduction. The traction should be mod- 
erate and, above all, steadily continuous ; and, generally speaking, the 
fragments should be brought parallel to each other before the traction is 
begun ; the latter is then made in the direction of the long axis of the 
limb. It should be continued for a few moments, while the surgeon 
watches the change in the length of the limb and in the relation of the 

1 Dictionnaire Encyclopedique des Sciences Med., 4tli series, vol. iv. p. 70. 



TREATMENT OF FRACTURES. 157 

fragments to each other, and makes gentle pressure on the sides of the 
limb to overcome lateral displacement. If the bone is superficial and 
the swelling moderate he may be able to recognize plainly the irregu- 
larities of the surface due to the displacement, and note their disappear- 
ance when the reduction is complete ; but if the bone is covered by thick 
muscles his only guide may be the length of the limb, of which he can 
judge by his eye, or by measurement. Sometimes reduction takes place 
with distinct crepitus, but the sign is of no great value, since it is some- 
times absent in complete, and present in partial, reduction. While the 
effort is making the patient must be enjoined to maintain as complete 
muscular relaxation as possible ; he should be recumbent, and should not 
be allowed even to raise the head, and this quiescence should be main- 
tained until after the retaining dressing has been applied. 

It goes without saying that the reduction must include the other dis- 
placements, as well as the longitudinal and transverse, and in fracture of 
the lower extremity especial care must be given to the correction of 
rotatory displacement, and with that view the attention must be directed 
to the relations of the different bony prominences which may serve as 
guides, and they must be carefully compared with fixed and known 
standards, or with those furnished by the other limb. 

It sometimes happens that complete reduction is difficult or impossible 
for other reasons than those already mentioned. Thus, when a small 
spongy bone or the expanded extremity of a large one has been crushed, 
so that there is an absolute loss of substance embracing the whole or 
only a portion of the thickness, either with or without impaction of one 
fragment in the other, it may be impossible to grasp the pieces so as to 
make the traction necessary to separate them, or to keep them, if sepa- 
rated, at a proper distance on account of the destruction of the inter- 
mediate portion. An instance of this firm impaction is reported by 
Stanley. 1 A man received a fracture at the lower end of the leg by the 
passage of a cart-wheel over it. All attempts to reduce the displace- 
ment were ineffectual, and after his death on the tenth day, and the re- 
moval of the soft parts by dissection, it was found difficult to separate 
the fragments, so firmly were they impacted. A similar case, of impac- 
tion at the lower end of the radius that could be overcome only by con- 
siderable force after dissection, has been reported by Dr. L. S. Pilcher. 2 

The same difficulty may be experienced after fracture of the diaphysis 
with much comminution, either because the small fragments become 
lodged between the large ones in such a way as to effectually oppose 
their adjustment, or because their minute shattering and compression 
produce the effect of an absolute loss of substance in their failure to 
afford support. Even when the comminution involves only a portion of 
the thickness of the shaft the same difficulty exists, because the remain- 
ing portions touch each other by too limited an area. Or the projec- 
tions of a toothed fracture on one fragment may be engaged in other 
than their corresponding depressions on the other one, and the best 
efforts of the surgeon may be ineffectual to disengage them. Or, in an 

1 London Med. Gazette, 1844-45, vol. i. p. 274. 

2 Annals of Anatomy and Surgery, March, 1881, p. 116. 



158 TREATMENT OF FRACTURES. 

oblique fracture the anterior point, for example, may have been carried 
behind the posterior one, and the condition may not be recognized. 
Lisfranc is reported to have reduced the displacement in such a case by 
carrying the fragment laterally around the other, a manoeuvre which 
could not be expected to always succeed even if the diagnosis were 
correctly made. 

When the fracture involves the ankle-joint the external malleolus and 
foot may be dislocated outwards so far as to allow the astragalus to slip 
up between the tibia and fibula, as in figure 49, and to be wedged there 
too tightly to permit of reductien by the means usually at command. 
An example of this displacement, irreducible during life and verified by 
autopsy, is reported in the Bulletin cle la Soeiete de Chirurgie, 1880, p. 
436. The patient was a woman, 58 years old, and had produced the 
fracture by an effort to draw off her boot with her hands, the foot twist- 
ing outward. 

There are other cases, too, in which reduction cannot be made because 
it is impossible to act upon the displaced fragment on account of its 
small size, or of the depth at which it is placed. Examples of the first 
are presented in fracture of the patella, of the coronoid process of the 
ulna, and of other small apophyses to which powerful muscles are at- 
tached, and also of fragments, articular or otherwise, which have been 
displaced to a considerable distance. Examples of the second are seen 
after extreme displacement or rotation of the articular end of a long 
bone after its separation from the shaft by fracture ; and a somewhat 
similar condition is found in fractures combined with dislocation. The 
same inability to properly handle the fragments is found also after frac- 
ture of the trunk or head, and frequently involves permanent deformity. 

Finally, a serious obstacle to reduction may exist in the perforation 
of the overlying muscles and fascia by the sharp end of a fragment, or 
in the interposition of a bundle of muscle between the fragments. It is 
all the more serious because it is often difficult of recognition, and, when 
uncorrected, results in failure or retardation of union, or in union by an 
insufficient callus. An interposed bundle of muscle, if small, may be- 
come imbedded in the callus and disappear after a time by absorption, 
and therefore expectative treatment may properly be followed ; but 
when the end of a fragment has penetrated a muscle to a considerable 
depth, the displacement must be overcome. The accident is most com- 
mon in oblique fractures of the lower portion of the femur and of the 
upper portion of the humerus, the penetration being made by the lower 
end of the upper fragment in the former case, and by the upper end of 
the lower fragment in the latter. Recourse is first had to full extension 
in the hope of thus withdrawing the bone from the tissues in which it 
has buried itself. That failing, an operation becomes necessary sooner 
or later. It has been recommended and practised to insert a tenotome, 
divide the muscle below the end of the fragment by short cuts, and then 
to press the divided surfaces away, and thus open a route for the return 
of the bone to its place. In a case in which Laugier is said to have 
thus divided the perforated fascia of the thigh an abscess formed and 
led to the death of the patient by pyaemia. Nevertheless, I think few 
surgeons would hesitate now to cut freely down upon the bone, under 



TREATMENT OF FRACTURES. 159 

antiseptic precautions, for the purpose of correcting an otherwise irre- 
mediable displacement which, if left to itself, would cause complete 
disability. When the perforation involves the skin also, and the frac- 
ture is already compound, there can be no hesitation. Nothing is lost 
by enlarging the wound and thus gaining an opportunity to make the 
reduction intelligently, and, therefore, with the least laceration and 
violence. (See Treatment of Compound Fractures.) 

Retention. — It occasionally happens that the tendency to displace- 
ment is so slight that, after the reduction of the fracture, the limb may 
be left without other dressing than such as may be designed to protect 
it from accidental violence. But in the vast majority of cases a dress- 
ing is required to resist the tendency of the muscles or of gravitation to 
produce displacement, and to secure immobility ; and the same indica- 
tions exist also in those cases in which only incomplete reduction is 
possible. The principles that govern the construction of the retaining 
apparatus are closely allied to, and sometimes identical with, those of 
reduction. In some cases the best retaining dressing is a moderate, 
continuous, active extension, supplemented by lateral support at the 
seat of fracture ; in others it is rather a passive extension, that is, a 
fixed inelastic apparatus, which, while not making extension, resists 
retraction ; in others, again, it is mainly lateral support to prevent 
angular or transverse displacement and to secure immobility. The 
details require that points of special pressure shall be guarded by 
cotton-batting, wool, or compresses, and that the limb shall not be 
wrapped circularly in such a manner as to expose it to gangrene. It 
may be necessary to bandage the distal portion of the limb to prevent 
oedema ; but except under rare conditions when its use is clearly indi- 
cated, such as hemorrhage, a roller-bandage should not be applied to the 
broken or upper portion of the limb under the splints. If pressure is 
desired to reduce a swelling or moderate inflammation, it should be 
elastic or at least capable of yielding, if the pressure is increased from 
within, and, in addition, should be most carefully watched. The best 
material is cotton-batting applied smoothly and evenly under a bandage. 
Pain cannot be depended upon to give warning of too great pressure or 
impending gangrene ; the fingers or toes should be left exposed to view, 
and the surgeon should make it an invariable rule to examine their sen- 
sitiveness and the circulation in them by pressure upon the nails and by 
feeling for pulsation in any accessible distal arterial branch immediately 
after a dressing has been applied, and at every visit for the first few days 
thereafter. If it is feared that the principal vessels or nerves have been 
injured by the accident, it is often best not to attempt complete reduc- 
tion and retention at first, but merely to support the limb in a good 
position until the full extent of the injury shall have become apparent. 
In many litigations the question upon which the verdict depended has 
been whether the gangrene was due to the original injury or to an ill- 
applied dressing, and the surgeon should protect himself as far as possi- 
ble against the doubt. 

The choice of a dressing in simple fractures uncomplicated by severe 
injury to the soft parts depends in a measure upon the character of the 
displacement the tendency to which it is designed to correct ; and 



160 TREATMENT OF FRACTURES. 

although many of the dressings and splints meet more than a single 
indication of this kind, and although, furthermore, an indication can 
usually be met in more than one way, it seems best to describe the 
dressings as nearly as possible in groups based upon this pathological 
difference. I shall describe only those that are now in general or occa- 
sional use, and shall leave some details to be noticed in connection with 
special fractures. 

The first group comprises those which are intended simply to im- 
mobilize the limb or to effect contention by pressure, usually lateral. 
They are theoretically applicable especially to meet the tendency to 
transverse or angular displacement. The second comprises those which 
make active extension, or which maintain an extension previously gained. 
Their primary object is to overcome longitudinal displacements. These 
two forms merge into each other by intermediate forms possessing the 
qualities of both in varying proportions. Dressings are also classified 
sometimes according to the facility with which they may be readjusted 
or removed, as movable, immovable, and amovo-inamovible or removable- 
fixed. The first class includes all composed of bandages, cushions, and 
splints ; the second includes those which harden after they have been 
placed upon the limb, such as the starch, dextrine, and gypsum dressings ; 
and the third those composed of hardening materials arranged in sec- 
tions that permit removal without destruction of the dressing. 

The Scultetus Bandage (figs. 78 and 79). — This is a combination of 
short bands and wooden splints which was in very general use before 
the introduction of fixed dressings, and is still employed in some excep- 
tional circumstances. It is composed of a large number of small bands, 
a broad cloth, two long wooden splints, and two long narrow cushions 
made of muslin stuffed with horse-hair, cotton, wool, or straw. It is 
prepared for use as follows : A piece of stout cotton cloth, of a length 
and breadth somewhat greater than the length and circumference of the 
limb that is to be immobilized, is spread out upon a table ; then, be- 
ginning at its upper end, bands of the same material three or four inches 
wide, and one-half longer than the circumference of the limb are placed 
transversely upon it, each successive band overlapping the lower border 
of its predecessor about one inch. The cushions and the splints, each 
having about the length of the first piece of cloth, and a breadth of three 
or four inches, are placed along its sides, the edges of the cloth turned 
over them, and each rolled in until they meet in the centre. The band- 
age is now ready for transportation or use. If required, for example, 
for a fracture of the leg, the limb is raised from the bed, the bandage 
placed lengthwise under it so that its lower border projects a little be- 
yond the loot, and is unrolled, and the limb lowered upon it. One end 
of the lowest transverse band is raised, carried over the front of the leg 
and around the other side as far as it will go, and its other end brought 
back over it in like manner. This is repeated with each successive 
band, and after all have been applied the splints are rolled up in the 
broad piece of cloth, one on each side, until they rest against the side 
of the leg, separated from it, however, by the cushions, and the whole 
is secured by a few strips of bandage. Sometimes a short anterior pad 
and splint are added. 



TREATMENT OF FRACTURES. 



161 



The advantages of the dressing are the facility with which the limb 
can be uncovered without disturbing it, and the equable and gentle 
pressure which it makes. Its disadvantages are its complexity, and its 



Fis:. 78. 



Fig. 79. 





The Scultetus bandage ready for use. Th< 
not shown. 



splints and cushions are 



Scultetus bandage applied 
to the leg. 



Fiff. 80. 



comparative inefficiency to prevent displacement. Its use is now gene- 
rally restricted to cases which do not admit of a more efficient apparatus 
on account of inflammatory swelling, threatening gangrene, or extensive 
contusion, and to some compound fractures in 
which the antiseptic gauze is applied in this 
manner. It is seldom applicable except to frac- 
tures of the leg. It must be borne in mind that 
it is not incapable of causing strangulation of 
the limb, and therefore calls for the same 
watchfulness as other enveloping dressings. 

Bivalve cushion (figs. 80 and 81). This is 
a simple dressing that can be readily made of 
materials that are always at hand, and is there- 
fore of great use to the country practitioner or 
in an emergency, and meets very well the in- 
dications of treatment during the first few 
days. It was invented by a French surgeon, 
named Laurencet. A rectangular sac of stout 
cotton cloth, of a length and breadth suited to 
the size of the limb, is divided into two parts by a seam which, be- 
ginning at the centre of its lower border, passes directly upwards for 




Bivalve cushion. 



162 



TREATMENT OF FRACTURES 



one-third its length, and then bifurcates so as to leave a central V- 
shaped portion, the base of which is at the upper border of the sac, and 
is about three inches wide. The two lateral pouches thus formed are 
stuffed, and the. openings closed. The limb is then placed along the 
centre, the two sides raised and supported by lateral splints, and the 
whole secured by the straps. If used in fracture of the leg, it is well 
to have the lower end of the sac project sufficiently beyond the sole of 
the foot to allow it to be turned in and fixed so as to support it. 
Yalette speaks very highly of the firmness and. security of this dressing; 

Fig. 81. 




Bivalve cushion applied to the leg. 

as the cushions are united to each other, they cannot become displaced 
with the facility which characterizes separate lateral pads and splints. 

Wooden splints are made preferably of soft white wood which lends 
itself easily to the cutting and shaping necessary to make them fit. 
Their main use is as lateral or coaptation splints, padded or applied over 
cushions so as to fit accurately without undue pressure upon prominent 
points. They are also serviceable in some compound fractures to give 
the necessary solidity while allowing easy exposure of the wound. A 
splint is made by cutting the wood to fit approximately the limb in length 
and breadth ; cotton cloth is then stitched loosely about it with an open- 
ing left at one end through which the padding, cotton, wool, curled hair, 
or some similar material, is introduced and distributed according to need, 
or cotton batting is laid upon the splint and secured by wrapping it with 
a bandage or thread. The carved splints prepared and offered for sale 
by dealers in instruments are vigorously condemned by most authors, 
and rightly so, in my judgment, if they are assumed to be fit for use 

in the shape in which they are 
offered. They need the same pad- 
ding and adjustment that an im- 
provised splint does, and their prin- 
cipal advantage is that, beingalready 
partly modelled, they need some- 
what less. A convenient form for 
some cases is Gooch's flexible 
wooden splint, which is made of thin narrow strips pasted close together 
upon stout cloth or leather (fig. 82). 



82. 



Gooch's flexible wooden splint. 




TREATMENT OF FRACTURES 



163 



Fracture boxes are a variety of the wooden splint applicable to frac- 
tures of the leg. Their use in simple fractures is mainly a temporary 
one, because there are other and better permanent dressings, but they 
are frequently used in compound fractures throughout the entire period 



Fio-. S3. 




Petit's fracture box. 

Fisr. 84. 




Scheuer's box splint. 



of treatment. Figures 83, 84, and 85, show the principal varieties and 
render a detailed description unnecessary. They must be fitted with 



Fisr. 85. 




Baudens's fracture box. 



cushions and pads for the reception of the limb, and with bands or straps 
to immobilize it and prevent displacements. It is well to support the 



164 



TREATMENT OF FRACTURES. 



Fig. 86. 




foot by a broad strip of adhesive plaster, which, beginning well up on 
the calf, is brought under the heel and along the sole of the foot, and 
tacked to the top of the foot-piece of the splint. By this means painful 
pressure upon the heel can be avoided. 

Gutters made of wire in a great variety of patterns are also in fre- 
quent use, and occupy a position intermediate between fracture boxes and 
moulded splints. A galvanized wire frame, or wire gauze strengthened 
at the edges, shaped to roughly fit the limb, is padded with cotton or 
cushions and bound on firmly by means of circular straps or bands. 

Those intended for the upper 
extremity are usually bent at 
a right angle at the elbow, 
those for the lower extremity 
straight or slightly bent at the 
knee, cut out at the heel, and 
fitted with a short cross-piece 
at that end to prevent rotation. 
Sometimes they are jointed at 
the knee or elbow, and in some 
cases the sides are hinged. 
Wire gauze is more commonly 
used now than wire frames, and 
the meshes of the latter should 
be smaller than those shown in 
figure 86. This mode of dress- 
ing has found its most complete 
expression in Bonnet's large gutters for the treatment of fractures of 
the thigh, which support the entire body, or in Palasciano's modification 



Wire gutter for th 




Bonnet's gutter for the leg. 



which is jointed at the hip, and allows the limb to be placed in the ex- 
tended or flexed position. The material yields sufficiently to lateral 
pressure to allow a certain amount of modeling to the irregularities of 
the limb, and as they are open in front an anterior pad and splint can be 
used if needed. 

Posterior and suspended splints are classified by foreign writers as 
liyponarthecic (from vrto under, and vapfljji, a splint^), a term which at 
first, as its etymology indicates, was applied only to posterior splints, 
but is now used to designate all suspended dressings. The aims of these 



TREATMENT OF FRACTURES. 



165 



dressings are to maintain the limb, especially the lower one, in a flexed 
position, to permit movements of the body without disturbance of the 
fractured bone, and to enable the surgeon to examine all portions of the 
.limb and to dress its wounds 
with the least disturbance and 
pain. The varieties are numer- 
ous, but follow two main types : 
a firm posterior splint or support 
upon which the limb rests ; and 
an anterior frame or splint from 
which the limb is suspended by 
bands or sheets passing under 
it. In either case the splint is 
suspended from a cradle or a 
hook at a certain height above it. 
The simplest, and, perhaps, the 
least efficient, is Mayor's (fig. 
88), composed of a plank or 
wire frame suspended by cords 
attached to its corners. The 
limb rests upon it on a cushion 
and is immobilized by bandages 
fastened about the foot and dif- 
ferent portions of the limb. Mclntyre's splint provides also for con- 
tinuous extension, and, combined with Salter's suspension cradle (fig. 
89), is a favorite dressing. Nathan R. Smith's anterior splint (fig. 91) 




Mayor's suspension dressing 



Fiff. 89. 




Mclntyre's splint and Salter's swing. 

was much used during the War of the Rebellion in the treatment of 
gunshot fractures of the thigh. It is composed of two parallel pieces 
of stout iron wire joined at the ends and by two or three intermediate 
rods, slightly flexed at the knee, and bent upwards at each end to fit 
the foot and the pelvis when the thigh is flexed. It is placed along the 
anterior surface of the limb and is bound to it by a roller bandage or 



166 



TREATMENT OF FRACTURES. 



by straps. A pulley and rope furnished with two hooks provide for 
suspension. Hodgen's splint (fig. 92) is similar in construction, but 



Fig. 90. 




Suspended fracture box for compound fractures. 



gives a firmer support and provides permanent extension in fractures of 
the thigh, if, as he suggests, the supporting hook is placed beyond the 



Fig. 91. 




a 



a 



i j? i 



Nathan E. Smith's anterior splint. 

foot, or if it is fitted with an extension apparatus. Mr. Bryant 1 says, that 
in seventeen cases of fracture of the femur treated at Guy's Hospital 
by this splint the average shortening was less than half an.inch, and that 
in six cases there was none. He found, however, after a lengthened 
trial, that a much larger amount of callus was formed than when he used 
the double lateral extension splint, and inferred that there was more 
mobility during treatment with the former than with the latter, and 
therefore discarded the Hodgen. 

Hodgen's cradle (fig. 93) is also highly recommended for compound 
fractures of the thigh. It is made of four wooden bars diverging from 

1 Surgery, 3d Am. edition, p. 848. 



TREATMENT OF FRACTURES 



167 



a foot-piece and supported by a cross-piece at the knee. The limb rests 
upon bands which pass from one upper bar to the other, and are adjust- 



Fie. 92. 







Hodgen's splint. 



able at different lengths by pinning, or by knotting, to meet the varying 
size of the limb. Permanent extension by India-rubber, or by a weight 



Fis. 93. 




Hodgen's cradle 
Fig. 94. 




Hodden's cradle with, extension. 



and pulley, can be used with it (fig. 94). (For adjustment of this 
method of extension see page 180.) 



168 TREATMENT OF FRACTURES. 

Splints made of plaster of Paris are sometimes used for suspension. 
Posterior ones are supported by bands ; anterior ones by cords attached 
to hooks, or wires imbedded in the plaster. Their construction will be 
described subsequently. 

31algaigne's point (fig. 95) is used in fractures of the leg to over- 
come the strong tendency which sometimes exists in the upper fragment 

Fig. 95. 



Malgaigue's point. 



to project anteriorly. Malgaigne found that an iron pin forced through 
the skin into contact with the bone was well tolerated, giving rise to lit- 
tle or no pain or inflammation. Fig. 96 represents the instrument in 
place. In one case in which he used it a fatal erysipelas originated at 



Fi£ 




Malgaigne's point applied. 

the wound, and this fact has brought some discredit upon the method, 
which, moreover, does not commend itself readily to the patient. It 
meets the indication very well, and I should not hesitate to use it in any 
case where the displaced end of the bone threatened to cause perforation 
and could not be otherwise reduced. It has been sought to obtain the 
same result by means of local pressure with a pair of padded rods, 
changing the pressure frequently from one to the other, so as to avoid 
sloughing at the points pressed upon. Fig. 97 represents such an appa- 
ratus ; but experience has shown that they are generally inefficient, 
because, notwithstanding the alternation, the skin is usually unable to 
bear the irritation. In fact, Malgaigne's point Avas devised as a sub- 
stitute for the other. 



TREATMENT OF FRACTURES 



169 



Fig. 97. 




Anger's apparatus for alternate pressure. 

Malgaigne' s hooks (fig. 98) are designed to hold the fragments of a 
broken patella together. They are a pair of hooks united by a movable 



Fig. 98. 



Fig. 99. 





Levis's modification in place. 



Malgaigne's hooks. 

screw. The points of one pair are forced through 
the skin and engaged in the upper fragment, 
those of the other in like manner in the lower, 
and the two are then joined and brought together 
by the screw. Vallette substitutes for the hooks 
a pair of forks attached by movable screws and 
rods to a gutter in which the limb lies ; and Levis 
prefers two separate sets of hooks (fig. 99), 
because they allow a more accurate adjustment 
to the irregularities of the bone. 

Moulded splints are constructed of any material that can be made 
temporarily soft enough to take accurately the shape of the part to 
which it is to be fitted, and which then becomes and remains hard enough 
to retain the shape that has been thus given to it. The materials most 
frequently used are pasteboard, leather, felt, gutta-percha, and plaster 
of Paris. 

Pasteboard or binder's board owes its availability to its quality of 
softening when placed in hot water, and of regaining its stiffness when 
it becomes dry. One or two strips, according to circumstances, are cut 
after a pattern made in paper, placed for a moment in hot water, moulded 
carefully to the limb, and secured in place by lateral splints and a roller 



170 TREATMENT OF FRACTURES. 

bandage until dry. When it is necessary to mould pasteboard at a right 
angle, as at the shoulder, longitudinal slits should be made in it, or 
V-shaped pieces taken out, since creases diminish the stiffness and make 
the pressure of the bandage uneven by their varying thickness. Care 
must be taken not to make the pasteboard too soft, for it then tears 
easily and, by losing some of its starch, becomes unable to regain its 
original stiffness. The details of its application, in a fracture of the leg, 
for example, are as follows : A pattern is made in paper of the lateral 
half of the leg and foot, and two strips of pasteboard cut according to 
it, of such dimensions that when fitted to the limb they cover the sides, 
but do not quite touch each other in front and behind. Reduction is 
then made, and the limb surrounded with a loose bandage, preferably of 
flannel, or with a thin layer of cotton batting ; the two splints, softened 
by immersion in hot w T ater, are placed one on each side and moulded ap- 
proximately to the leg and foot by gentle pressure with the hands, and 
then a roller bandage is snugly applied over them from the toes upward. 
This makes the fit accurate and close. Lateral wooden splints properly 
padded are placed on the sides and secured by bands or a roller band- 
age. Additional security is given by rolling up these lateral splints in 
a broad sheet of cotton cloth, as in the Scultetus bandage, the portion of 
the sheet between them passing under the limb. The pasteboard becomes 
dry in twenty-four hours, and then the lateral splints may be discarded. 

Moulded splints of leather, felt, or cloth stiffened with shellac are pre- 
pared and adjusted in like manner. Those stiffened with shellac can be 
softened by dry heat, but they become flexible only at a comparatively 
high temperature, and stiffen rapidly in cooling. It is therefore neces- 
sary to protect the limb against the heat by compresses or padding, and 
to make the adjustment rapidly. 

Gutta-percha is used in sheets or strips of the same length and breadth 
as the other materials, and from one-sixteenth to one-fourth of an inch in 
thickness, according to the size of the broken bone. It is softened by 
immersion in hot water, and Dr. Hamilton recommends that a large tray 
should be used for this purpose, in which the gutta-percha can be placed 
wrapped in a sheet of muslin. It becomes sticky as it softens and ad- 
heres to the muslin, which then serves to protect the hands of the sur- 
geon and the skin of the limb. If too hot and soft it must be slightly 
chilled by sprinkling it with cold water, and then rapidly moulded upon 
the limb. It hardens in fifteen or twenty minutes, and the process may 
be hastened by sponging it with cold water. 

Plaster of Paris or gypsum was first employed in Western Europe 
in the treatment of fractures early in the present century, having then 
been introduced from Turkey, where it seems to have been in use for a 
long time. It was used to make a solid mould about the limb by placing 
the latter, well-oiled previously, in a box and pouring in enough plaster 
to cover either the limb entirely or only its posterior two-thirds. The 
method was objectionable on so many accounts that its use never became 
general, and it was only after the introduction in 1852 and 1853 by the 
Holland army surgeons Mathysen and Van Loo of the method of applying 
it by means of bandages soaked in the cream that its availability and 
usefulness became apparent, and it earned the favor in which it is now 



TREATMENT OF FRACTURES. 171 

so widely held. It is used now in the form of anterior, posterior, and 
lateral splints moulded accurately to the limb, or as a complete encase- 
ment in simple fractures, and as a fenestrated or interrupted dressing 
strengthened by iron rods or bands in compound fractures. 

The application is usually made in one of two manners : either roller 
bandages of coarse cotton, or preferably of the thin open-meshed mate- 
rial known in commerce as crinoline, are filled Avith the dry powder 
and moistened when needed by immersion in water ; or bands or sheets 
of the same materials or of coarse flannel are soaked in plaster cream 
and then applied to the limb. The former method is used for complete 
encasement or interrupted dressings, the latter for moulded splints. The 
plaster should be fresh and perfectly dry, for if it has been so exposed 
as to absorb a certain amount of moisture from the air it is slow, or may 
fail entirely, to harden. Plaster damaged in this manner can be restored 
by thorough drying in an oven or over a fire. Roller bandages are 
prepared by unrolling them, rubbing the dry plaster thoroughly into 
their meshes, and re-rolling them ; if not to be used immediately, they 
can be preserved for a long time unchanged by wrapping them in oiled 
paper or by keeping them in a closely covered tin box. When needed for 
use, they should be placed on end in water deep enough to cover them, and 
gently pressed to force out the air ; on removal the excess of water 
should be squeezed out. Plaster cream is prepared by placing the quan- 
tity of water judged necessary in a basin and slowly sifting the dry 
plaster in until the mass reaches the surface. It should not be stirred, 
for stirring hastens the "setting." If it is desired to delay the setting 
beyond the usual time, a pinch of cream of tartar may be added to the 
water, or a little gelatine, two or three parts to a thousand of water. The 
addition of common salt or the use of hot w T ater hastens the setting. 

Moulded plaster splints are best made of from eight to fifteen thicknesses 
of crinoline folded to form a rectangle of suitable size or cut to the de- 
sired shape. Before being placed in the plaster cream they should be 
dipped in water and thoroughly wrung out ; then they are partly un- 
folded, or, if made of separate pieces, divided into portions of two or 
three pieces each, passed through the cream, which is well rubbed into 
them, or the cream applied with a spoon, refolded or replaced together, 
stripped down between the hands to remove the superfluous water, and 
applied to the limb directly or with an intervening compress. At 
points where the splints need to be bent at a considerable angle, as at 
the heel, elbow, or shoulder, they should be cut partly through in the 
line that would be taken by the folds if they were not cut, and the edges 
of the cut interlaced. It is well to make the cuts in the different layers in 
lines that do not exactly correspond with each other, in order that the sub- 
sequent union may be more uniform and solid. A simple fold at such a 
point diminishes the solidity of the splint. The application of a dry rol- 
ler bandage outside the splint insures retention of the shape and hastens 
the setting. If there is any tendency to displacement of the bone, reduc- 
tion must be maintained by the hands until the hardening is complete. 

Splints thus prepared may be made impervious to water by brushing 
them over several times with shellac varnish or by pouring melted par- 
affine upon them ; the varnish and the paraffine, if sufficiently hot, will 



172 



TREATMENT OF FRACTURES 



Fig. 100. 



soak through the entire thickness of the splint and protect it perfectly 
from subsequent shortening ; or the splint may be removed and the par- 
affine applied on the inside as well as on the outside. This precaution is 
very desirable when the fracture is complicated by a suppurating wound 
in order to preserve the solidity of the splint and avoid the necessity of 
changing it on account of its saturation with the decomposing discharges. 
Another, but inferior, method is to place a piece of oil-silk between the 
limb and the splint and reflect it over the edge of the latter. 

The splints may be anterior, posterior, or lateral, and the former may 
be readily fitted for suspension by imbedding in them hooks, or stout 
telegraph wire bent to form projecting loops at convenient distances. 

They may also be made somewhat lighter 
without loss of strength by placing thin 
strips of tin, wood, or iron longitudinally 
between their folds, and omitting some 
of the layers of the cloth. The posterior 
splint (fig. 100), combined with a single 
or double lateral one, is very serviceable 
in fractures of the lower end of the leg; 
the posterior splint should be long enough 
to reach from an inch above the toes 
around the heel nearly to the knee, or 
better, perhaps, three or four inches 
above it ; and the lateral one should be 
wrapped first about the instep and then 
carried up the leg to the same height as 
the other, or it may be double, passing 
under the instep like a stirrup. The 
projection of the posterior splint beyond 
the toes serves to keep the weight of the 
bed clothing from them. MacCormac 
recommends a combination of anterior 
and posterior splints for fractures of the 
leg, either simple or compound. The 
shape of the splints and the appearance 
of the limb when thus dressed are shown 
in figs. 101 and 102. The splints must be narrow enough not to come 
into contact with each other at their edges. 

The Bavarian, book-back, or bivalve plaster splint (fig. 103), is 
designed to afford a convenient means of inspecting the broken limb 
during the treatment. It is made of two pieces of coarse flannel that 
has been shrunk and cut of the proper length and of a width somewhat 
greater than the circumference of the limb. These pieces are then 
fastened together by two rows of stitching about half an inch apart 
along the centre, which, in the case of the leg, is to occupy the posterior 
median line, and placed in position under the limb. The one that is 
next to the leg is then folded around it and its free edges stitched 
together in front and along the dorsum and sole of the foot, plaster 
cream is spread smoothly over it and well rubbed in, and the outer layer 
of flannel then drawn over and stitched or pinned fast in like manner. 




Posterior gypsum splint or gutter. 



TREATMENT OF FRACTURES. 



1T3 



After the plaster has set the stitches are cut, the excess of flannel cut 
away, and the edges bound by stitching those of each side together, or 



Fisr. 101. 




Strips to form anterior and posterior plaster splints for the leg. 
Fig. 102. 




The above applied. A, is a -wire bent into loops for the purpose of suspension. 

by binding on strips of leather provided with eyelets. The bandage is 
kept in place by a bandage or by a cord passed through the eyelets, and 

Fiar. 103. 




The Bavarian splint. 



can be readily removed, or one side can be lowered by turning it on the 
hinge which is formed by the narrow strip left between the two rows of 



174 TREATMENT OF FRACTURES. 

stitching behind. Mr. Bryant uses instead of plaster a mixture of preci- 
pitated chalk and mucilage of gum acacia. 

Zsigmondi, 1 of Vienna, recommends a splint made of a flat bag of the 
proper shape and filled with dry plaster. The bag is made of two pieces, 
one of cotton arid one of shrunk flannel, sewed together with an inter- 
posed piece of muslin of the same size. The two pouches of the sac are 
then filled with dry plaster spread evenly through them, and the whole 
dipped into warm water. The air escapes through a small opening left 
at the end where the plaster was introduced, aided by gentle pressure 
with the hands. The sac is removed from the water, allowed to drain 
for a moment, laid upon a table and pressed out evenly, then applied to 
the limb with the flannel next the skin, and fastened with a roller band- 
age. Angles in the limb are provided for by previously cutting out 
V-shaped pieces at the corresponding points in the sac and sewing the 
sides of the gap together, flannel to flannel, and cotton to- cotton. 

Complete encasement of a limb in plaster of Paris (fig. 104), the dress- 
ing that is generally meant when the expression " treatment by plaster of 

Fig. 104. 




Encasement of the leg in plaster of Paris. 

Paris " is used with reference to a fracture, is a dressing of great value. 
Introduced as a substitute for the starch and other " immovable " dress- 
ings, it inherited both their favor and disfavor, but by its general superi- 
ority to them and by the ease with which it lends itself to the treatment 
of compound fractures and operations upon the joints it has established 
its position, and is now in very general use, at one period or another of 
the treatment, although it has suffered somewhat from the exaggerated 
claims of its extreme partisans. The mode of application is as follows : 
after reduction of the displacement by extension the limb is enveloped in 
a sheet of coarse blanketing cut to fit it accurately, or by short roller 
bandages of the same or a similar material loosely applied, or, still bet- 
ter in my opinion, in a layer of cotton batting reinforced over the de- 
pressions and about the bony prominences and supported by a few turns 
of a roller bandage. Then the roller bandages, prepared as above de- 
scribed (p. 171), are applied in the usual manner from below upwards until 
a sufficient thickness has been obtained. They must be simply rolled 
around the limb, not drawn tightly. The limb meanwhile is supported 
and extension maintained by assistants, the bands are rubbed smooth by 
the surgeon, strips of thin wood or metal interposed at intervals to in- 
crease its strength, if necessary, or a wire for suspension, and when 

1 Bulletins de La Societe de Chivurgie, 1878, p. 653. 



TREATMENT OF FRACTURES 



175 



the dressing is completed the limb is lowered upon the bed and the ex- 
tension maintained until the plaster has set. In fracture of the leg or 
thigh the comfort of the patient can be increased by the use of Volk- 
mann's sliding rest for the foot. (See page 182.) 

In the lack of prepared roller bandages, or of the material spoken of 
as most fit for their construction, the dressing can be made of layers of 
any coarse cloth, as shown in fig. 105, _,. nA _ 

and soaked in plaster cream. 

A properly applied dressing should not 
only cause the patient no pain, but should 
produce even a feeling of relative comfort. 
Some sensitiveness may persist for a short 
time at the seat of fracture, but if it has 
not disappeared or become much less by 
the following day the cause should be 
sought for. If this seems to be tightness 
of the dressing, if the circulation in the 
exposed fingers or toes is interfered with, 
as shown by change of color, oedema, or 
loss of sensation, the dressing must be 
removed, or at least laid open longitudi- 
nally, to relieve the pressure and allow 
inspection. 

In fractures complicated by suppura- 
ting wounds fenestrse must be cut, which 
can be done with a sharp knife without 
much trouble, and the edges protected by 
shellac or paraffine. In order also to pre- 
vent saturation by the discharges of the 
cotton or blanketing that lies next the 
skin two or three pieces of oil-silk consid- 
erably larger than the wound should be 
placed upon it, and then, after the fenes- 
tra has been made, slit in different directions, turned out over the edge, 
and fastened down with varnish or collodion. If the wound is to be 
dressed antiseptically, or if the injury is severe and burrowing of the pus 
is feared, a fenestra of sufficient size would weaken the splint too much, 
unless its place were supplied by other means, and therefore bent rods or 
bands of hoop-iron must be imbedded in the dressing during its applica- 
tion, so as to bridge over the opening. These "interrupted" splints 
(figs. 106 and 107) are of many forms, and aiford opportunities for the 
exercise of much ingenuity and skill in their construction. The connect- 
ing rods should be stout, and if bands are used they should be so placed 
that their breadth, and not their thickness, shall be opposed to the expected 
strain. It is usually necessary therefore to have at least two of the latter, 
placed in planes that cross each other at or nearly at a right angle. A 
broad, stout posterior splint of iron imbedded in the plaster, and not 
bent like the others, gives much additional strength (fig. 107). 

Similar fixed dressings are made with starch, dextrine, and silicate of 
soda or potash. Their principle is the same, and each has its own spe- 




Plaster-of-Paris dressiug made of coarse 
sack cloth. (Esmarch.) 



176 



TREATMENT OF FRACTURES. 



cial advantages and disadvantages. The starch bandage, generally 
known in literature as Seutin's, and antedating the others, is made by 



Fia:. 106. 




Fenestrated plaster dressing. 

wrapping the limb in a roller bandage after protecting the bony promi- 
nences with cotton, and then applying numerous rollers saturated with 



Fie. 107. 




Interrupted plaster dressing. A, the straight posterior iron splint. 

starch, and having longitudinal and spiral strips of pasteboard interposed 
between the layers. It requires about forty-eight hours to harden com- 
pletely, and during this time the reduction must be maintained by appro- 
priate external splints. After hardening, the dressing is divided longi- 
tudinally and refastened with a bandage if it is found to fit properly, 
relaxed if too tight, or made tighter if too loose, by cutting out a strip 
along the line of section. The substitution of a tolerably thick layer of 
cotton batting for the first roller bandage is a valuable modification. 
Dextrine was substituted for the starch by Velpeau, because it hardens 
more rapidly, within a few hours. It is obtained in the form of a pow- 
der, which must be prepared for use by mixing it first with alcohol, and 
then reducing it with hot w r ater to the proper consistency. Roller band- 
ages are then unrolled and re-rolled in it, squeezed thoroughly, and applied 
to the limb in the usual manner over a dry bandage or a layer of cotton. 
I have found it more troublesome to use than plaster, and quite as 
objectionable on the score of uncleanliness ; its superiority to plaster is 
in its lightness. 



TREATMENT OF FRACTURES. ITT 

Silicate of soda or potash (water glass) hardens more quickly than 
dextrine, is equally light, and is ready for use in the form in which it is 
obtained. It is a clear, slightly amber-colored, syrupy liquid, with 
which the roller bandages are saturated in the same manner as with 
dextrine ; it is less rigid than plaster, and it has occasionally happened 
that extensive sloughing has been caused by its contact with the skin. 

Quite recently Von Langenbeck 1 has recommended a new cement, 
known as tripolith, as a substitute for plaster. He claims for it that it 
remains unaffected by the air, while in the condition of powder, for a 
longer time than plaster, that it is 14 per cent, lighter, hardens more 
rapidly, is a trifle cheaper, and w T hen once hard and dry is impervious 
to water. It is applied in the same manner as plaster. Its composition 
is a secret, and it is manufactured for use in stucco work. I do not 
know if it can be obtained in this country. 

The advantages of the plaster dressing, as compared with the other 
immovable ones, excepting tripolith of which I have no experience, are : 
1st, that it hardens so rapidly that reduction can be easily maintained 
for the necessary length of time without the aid of splints ; 2d, that it is, 
on the whole, more solid, and therefore better able to prevent subsequent 
displacement ; 3d, that it is sufficiently porous to allow some ventilation of 
the limb ; 4th, that it is simple and cheap. Its disadvantages are its 
w T eight, its destructibility by water, and the impossibility of removing it 
temporarily. If such removal is required a new dressing must be made, 
or the original one must be made in the form of two or more splints, as 
above described. It ought to be unnecessary to add that it can yield no 
better result in the way of shortening than can be obtained at the time 
of the reduction ; the most that it can do is, of course, to preserve the 
length that exists at the time it is applied, but in the controversies to 
which it has given rise this fact seems to have been lost sight of occa- 
sionally on both sides, and the relative merit of the dressing has been 
judged by the results found at the end of treatment, without considera- 
tion of the characteristics of the recent fracture. Its efficiency depends 
also in great part upon the existence of suitable points for counter-pres- 
sure ; the mere encasement of a limb in plaster will not prevent shorten- 
ing if the limb can move longitudinally within its case ; the soft parts 
cannot be depended upon to prevent this motion, because they shrink 
somewhat during the treatment, and the limb lies loosely within the 
dressing. Bony points or surfaces inclined at an angle to the longitudi- 
nal axis on each side of the fracture are alone sufficient, and these can- 
not always be found, or made use of. For this reason, while the dress- 
ing is excellent for fracture of the leg, it cannot be depended upon with 
certainty in fracture of the thigh or of the humerus, because in both 
these cases it is difficult to obtain an upper fixed point, and I therefore 
prefer to postpone its application in a fracture of the thigh until after 
the third or fourth week, when the partial consolidation of the callus 
aids to prevent shortening. Some surgeons, however, use the immova- 
ble apparatus, either of starch or plaster, in all simple cases of fracture 
of the thigh from the very beginning, and do not keep the patient in bed 

1 Berlin. Klinischer Wochenschrift, 1880, No. 46. 
12 



178 TREATMENT OF FRACTURES. 

for more than three or four days. Erichsen 1 says he has treated many 
in this way " and without the slightest shortening or deformity being 
left. The points to he especially attended to are, that the back paste- 
board splint (in the starch dressing) be very strong, at the upper part 
especially, and that the spica be well and firmly applied, so that the hip 
and the whole of the pelvis may be immovably fixed." 

The liability to gangrene, general or local, due to its use, has, I think, 
been overestimated in consequence of a few unfortunate cases, in some 
of which, even, the real agency has perhaps not been recognized. I 
have known the perineum to slough deeply in consequence of the pres- 
sure made upon it by the edge of a dressing applied for a fracture of 
the femur, and that is an illustration of the difficulty just mentioned of 
finding an upper fixed point in such cases, and I have treated a fracture 
of the leg that had become compound by the sloughing of the skin under 
the plaster, but in this case the sloughing was attributed to the coexist- 
ing contusion rather than to undue pressure made by the splint, and from 
what I could learn of the conditions I am inclined to think it would have 
occurred if the fracture had been treated in any other manner. In 
short, it is blind partisanship that claims for plaster success under all 
circumstances, and it is equally blind prejudice that holds it responsible 
for all complications that arise under it. Like any other dressing, it 
must be used judiciously and not in a routine manner, and its limitations 
as well as its merits must be recognized. I should hesitate to apply it 
immediately after the accident if the patient could not be frequently 
seen during the next forty-eight hours, and although the cotton or 
blanketing placed under it is, in the immense majority of cases, a per- 
fectly efficient precaution against excessive local pressure, yet it must be 
remembered that extensive slouching has occurred under such circum- 
stances and is inexplicable on any other theory than that of pressure 
except by resort to unsubstantiated suppositions of nerve injury. It is 
well known that early reduction and perfect retention diminish mate- 
rially the subsequent inflammatory processes, and therefore, since the 
plaster dressing is in suitable cases the most efficient means of retention, 
it should be applied at the earliest possible moment, and as the only 
danger is that of undue pressure, watchfulness ought to be a sufficient 
protection. The interposition of a thick layer of cotton is an absolute 
guarantee against this danger but diminishes the accuracy of the re- 
tention. 

Gurli 2 recommends the immediate application of the plaster very 
strongly on the ground that, so far from causing gangrene, it acts as a 
most efficient antiphlogistic by virtue of the equable pressure which it 
exerts, as well as by its immobility. He recognizes certain exceptions 
in which the dressing must be used with caution, if not entirely rejected. 
These are : present or impending gangrene ; extravasation of blood suf- 
ficient to stretch the skin notably ; injury of a large artery, making the 
formation of a false traumatic aneurism probable ; and, finally, the ex- 
istence of acute erysipelatous or phlegmonous inflammation. 

1 Science and Art of Surgery, Am. ed. 1873, vol. i. p. 377. 

2 Loc cit. 7 vol. i. p. 472. 



TREATMENT OF FRACTURES. 179 

It has been alleged, that failures of union are more common in frac- 
tures treated with plaster, but the allegation appears to be unfounded. 

The double-inclined plane (fig. 108) is designed to maintain reduction 
after fracture of the femur by continuous extension supplied by the 
weight of the pelvis. It consists essentially of two posterior splints, femo- 
ral and tibial, united by a hinge at the knee, and kept at the chosen 

Fig. 108. 




Esmarch's double-inclined plane. 

angle by a horizontal plank upon which it rests, or by a rod, or by straps, 
or by suspension of the tibial portion. The limb rests on cushions placed 
upon the splint and is fastened to it by bandages or by lateral pegs in- 
serted vertically. It is essential that the femoral splint and the hori- 
zontal plank shall not support the pelvis ; this must be left free to sink 
into the mattress and thus furnish the desired extension. Mayor modi- 
fied this apparatus by making it of wire and broad enough to bear both 
limbs, using the uninjured one as a sort of splint to secure the other in 
a good position. Mr. Bryant says he has found it very valuable in frac- 
tures of the upper third of the femur where the upper fragment is apt to 
tilt forward and rotate outwards, but it should be used only when other 
means fail, and it is daily dropping out of use. 

The treatment of fractures by continuous extension applied to the 
distal segment of the limb has been in use for centuries, the means em- 
ployed being a weight and pulley or an adjustable screw passing through 
the foot piece of a long splint in fractures of the thigh, for example. 
Counter-extension was maintained by a perineal band attached to the 
head of the bed in the former case, and to the upper end of the long 
splint in the latter. The disadvantages were serious ; if the extension 
was efficient the pressure produced upon the dorsum of the foot and 
about the ankles by the bands through which it was made caused pain 
and, if prolonged, sloughing ; if moderate enough not to cause this 
result it was insufficient to prevent shortening, and the surgeon's time 
was spent in alternately increasing and diminishing the traction to meet 
first one and then the other indication. The patient too often found his 
convalescence retarded by a slough and his limb permanently shorter by 
one or two inches. 

The first important modification was the substitution of long strips of 
adhesive plaster for the bands and girdles by which the weight or the 
screw was attached to the limb. This device entirely prevents pain and 
eschars, and allows the use of a traction of twenty or twenty-five pounds 



180 TREATMENT OF FRACTURES. 

without serious inconvenience to the patient. It appears to have been first 1 
employed not infrequently in Pennsylvania before 1848, and published 
by Sargent 2 at that date, and again independently by Dr. Josiah Crosby, 
who published it in the Transactions of the American Medical Associa- 
tion in 1850 (vol. iii. p. 382), but its popularization seems to have been 
due to Dr. Gurdon Buck, who introduced it on Dr. Crosby's suggestion 
into the N. Y. Hospital before 1852. In 1855, a specimen of the thigh 
splint as then used in the N. Y. Hospital was given by the late Dr. 
Suckley to Nelaton, and another was taken at the same time by Prof. 
C. R. Agnew to Dublin. 3 This was its introduction into Europe, and 
this method of making extension is frequently spoken of in foreign works 
as the " American method " of treating fractures. 

The next step in the development of the dressing here in America was 
the adoption of short coaptation splints and the discarding of the long 
splint and of the perineal band, and reliance upon the weight and pulley 
for extension, and upon the elevation of the foot of the bed to make counter- 
extension by the weight of the body sufficient. The raising of the foot 
of the bed was suggested by Dr. Van Ingen., of Schenectady, N. Y., in 
1857, 4 and, like the extension by adhesive plaster, was adopted and 
popularized by Dr. Buck. Dr. Hamilton still uses the long splint with 
a cross-piece at the foot to prevent rotation (fig. 113), but Volkmann's 
sliding rest (fig. 112) answers the purpose equally well and possesses 
additional advantages of its own. The substitution of an elastic for the 
rigid cord to suspend the weight seems to me of no importance if the 
pulley moves freely. Elasticity in the means of traction is of value 
only when one of the points is fixed ; as it can neither increase nor 
diminish the force exerted by a freely movable weight it adds nothing to 
the constancy or equality of the extension; and if it yields more readily 
than the weight alone would to a sudden twitch of the muscles it may be 
disadvantageous rather than useful by allowing a momentary mobility 
that the weight might prevent. 

In England and in France the long splint has been retained, and the 
extension is made more generally by an India-rubber cord with diverse 
methods of counter-extension than by the weight and pulley. 

The principle of the method of treatment by continuous extension is 
to tire out the muscles whose contraction causes displacement by a 
moderate but persistent strain upon them, one from which they are not 
relieved for several weeks. Its principal and most important use is in 
fractures of the shaft of the femur, but it may be used whenever the in- 
dications exist and a sufficient and suitable surface can be found for the 
attachment of the adhesive plaster, and when proper counter-extension 

1 The use of adhesive plaster by Grooch ahout one hundred years ago, referred to by 
Martin in the North Carolina Medical Journal, January, 1878, and by Prof. Van 
Buren in the N. Y. Medical Record, 1878, p. 242, and quoted by Dr. Hamilton in the 
sixth edition of his work, does not seem to justify the claim to priority made in his 
favor, for he used it, not to make extension in fractures, but only to flex the heel 
upon the leg after rupture of the tendo Achillis, just as it is used to draw together the 
sides of a gaping wound. 

2 Minor Surgery, Phila., 1848, quoted in a note of Crosby's paper. 

3 Van Buren, in N. Y. Medical Record, 1878, p. 241. 

4 Trans. Am. Med. Ass., vol. x. 1857, p. 436 ; quoted by Van Buren, loc. cit. 



TREATMENT OF FRACTURES 



181 



can be made. Such uses will be described in connection with the dif- 
ferent fractures to which they are applicable, and I shall mention here 
only the details of its use in fractures of the thigh. 

A band four or five inches wide of stout moleskin adhesive plaster, 
long enough to reach from a point on the side of the thigh a few inches 
above the knee loosely around the sole of the foot and back to a point 
opposite that at which it began, is notched in its middle portion and slit 
at the ends as shown in figure 109 ; a fiat piece of wood, five by three 

" Fiff. 109. 








inches and perforated in the centre, is secured in the centre of the strip 
by folding the edges of the latter over it, the folds being continued up 
to the notches (fig. 110) so as to cover in the adhesive surface of the 



Fig. 110. 




intermediate portion. The piece of wood must be longer than the dis- 
tance between the malleoli. A roller bandage is then applied to the 
foot, ankle, and lower third of the leg, the plaster placed on the sides 
of the limb above it, the foot-piece being about two inches below the 
sole of the foot, and secured there by carrying the bandage up over it; 
the upper ends of the plaster, if long enough, may be turned down and 
covered by a few additional turns of the roller. It is very desirable 



Fig. 111. 




Adhesive plaster applied for extension. 



that the plaster should be carried above the knee whenever possible, in 
order to avoid the prolonged strain upon the ligaments of the joint that 
is produced when the attachment is to the leg alone, and it is also well 
to pad the ankles with cotton before applying the roller. Short coapta- 
tion splints, usually four in number, or the flexible wooden, Gooch's, 
splints are strapped upon the thigh, the cord attached to the foot-piece 
by passing it through the central hole and knotting it on the inside, 



182 



TREATMENT OF FRACTURES 



carried over a pulley fastened to the foot of the bed, and made fast to 
the weights. Finally, the foot of the bed is raised six or eight inches, 
and the leg placed upon a Yolkmann's sliding rest. 

A^olkmann's sliding rest (fig. 112) is composed of a wooden frame, 
the side bars of which are triangular with an upper edge upon which 



Fig. 112. 




Volkmann's sliding rest for fractures of the thigh. 

two cross-bars rest. To these cross-bars are fixed a posterior splint 
and an upright foot-piece, the former cut away centrally in its lower quar- 

Fiff. 113. 




Long side splint. (Hamilton.) 



ter to accommodate the heel. The foot and leg are fastened to the 
splint by a roller bandage, and can thus be moved freely up and down 
the bed, the cross-bars which support them sliding without much friction 
upon the triangular side-pieces. This apparatus adds much to the com- 
fort of the patient, and moreover prevents rotation of the leg. It takes 
the place of the long side-splint and cross-bar (fig. 113). 



TREATMENT OF FRACTURES 



183 



Elastic extension without a weight and pulley is accomplished by 
means of stout India-rubber tubing attached to the leg by adhesive plas- 
ter as above described and to a long side-splint extending well up toward 
the axilla. Counter-extension is made by a perineal band fastened to 
the upper end of the splint, or by a band of stout cloth carefully fitted to 
the upper portion of the opposite thigh and carried, one end in front, the 
other behind the body, to the top of the splint, or by a cord attached to 
the end of a rod extending from the upper end of the splint in front of 
and well beyond the shoulder, and fastened by bands of adhesive plaster 
to the abdomen and back, or, finally, by bandaging the other thigh and 
leg securely to a second side-splint which is attached to the first by a 

Fig. 114. 




Indiaralher' 
Accumulator' 

Permanent extension by India-rubber. 



cross-piece at the foot and by a pelvic bandage or brace. Figs. 114, 
115, and 116 represent forms in common use. Mr. Bryant prefers the 



one shown in fig. 114. 



Fig. 115. 

Double ,'zidky 




IncLRubberAcwmulator 



Cripp's splint. 
Fig. 116. 




Roji c w i th Cc- n t- fasten er for 
Extension of affected limb 



Indict rubber 

Accumulator 



Campbell de Morgan's splint. 



The relative merits of, and the special indications for, these different 
methods of treating simple fractures have, I trust, been sufficently set 
forth in the preceding pages from the general stand-point to render a 
detailed comparison and judgment unnecessary at this time. They will 
be again referred to in connection with the special fractures or conditions 
to which each may be particularly appropriate. 



184 TREATMENT OF FRACTURES. 

A plaster dressing that has been applied after complete reduction, and 
under which all seems to be doing well, may be left unchanged until the 
expiration of the period usually sufficient for complete consolidation, the 
length of which varies with the age of the patient and the size of the 
bone. If, however, it is found to have become so loose by the shrinking 
of the limb as to afford apparently inadequate support, it should be re- 
moved and a new one applied, the opportunity being improved to correct, 
if possible, any displacement or faulty position that may have occurred 
under it. Other dressings require a more frequent examination in the 
later as well as in the earlier periods of the treatment, for displacements, 
especially the angular ones, may occur as late as the third, or even the 
fifth week, and then if not promptly detected may soon become irremedia- 
ble except by operation. In addition to the more thorough examination 
which is here referred to, one requiring more or less complete removal 
of the splints, frequent inspection without disturbance is required to de- 
tect change of position or the occurrence of any complication. Especial 
attention must be paid in the treatment of fracture of the upper portion 
of the leg or of the thigh to the detection and correction of outward ro- 
tation of the upper fragment, which is produced by the sinking of that 
side of the pelvis while the dressing keeps the lower fragment from 
sharing in the rotation. I have found this tendency very troublesome 
after excision of the knee, even when the leg and thigh were incased in 
plaster, and it has been pointed out by Gosselin in fractures of the leg. 

The opportunity afforded by a change of the dressing may be im- 
proved to communicate gentle movements to contiguous joints that have 
been immobilized but not involved in the fracture*, or to reapply the 
dressing with the limb in a different position. Opinions are divided 
upon the propriety of communicating movements to fractured joints, 
some surgeons preferring to maintain absolute immobility until con- 
solidation is complete, others communicating motion at regular and 
short intervals after consolidation is well begun, and others, again, using 
from the first dressings that support but do not immobilize, as a sling in 
fracture of the elbow. A notable discussion upon this point was raised 
in 1879 in the Societe de Chirurgie by Verneuil, himself an advocate of 
complete immobilization, and carried on during several sessions. No 
formal conclusions were reached, but the weight of testimony was in 
favor of immobility. Verneuil's argument was that the stiffness of a 
joint is the result of its inflammation, not of its immobility, and that im- 
mobility, being the best possible antiphlogistic under the circumstances, 
would diminish instead of increasing the stiffness. Whatever the sur- 
geon's opinion upon this point may be, it is very certain that he will 
have to be content with immobilization in many cases, because communi- 
cated movements are so painful that patients will not submit to them. 
He must wait until consolidation is complete, and then try to overcome 
the adhesions by regular exercise or by breaking them up under anaes- 
thesia. 

The same question arises, but is less serious, in the management of 
large joints adjoining a fracture of the shaft of a long bone. As has 
been shown, they may be affected by an arthritis due to a concomitant 
sprain, to extension, or to the spread of the inflammatory process set up 



TREATMENT OF FRACTURES. 185 

about the fracture, but the severity of this arthritis is seldom great, and its 
consequences not permanent except in the old and individuals constitution- 
ally predisposed to arthritic troubles. Immobilization may be safely em- 
ployed for several weeks, and it is exceptional to see a resulting stiffness 
that does not yield to moderate and natural exercise. It is desirable to 
hasten its disappearance by daily gentle flexion and extension of the 
limb as soon as the consolidation is sufficiently advanced to allow this to 
be done without danger of causing pseudarthrosis, and if the manipula- 
tions do not make the joint hot and tender. 

In the smaller joints of the hand the case is different. There the ex- 
tended position and immobility favor stiffening, even when the fracture 
involves only the forearm or arm, and therefore they should be left free, 
or dressed in the flexed position and moved every day. 

Local measures to prevent or reduce inflammation about a simple frac- 
ture are rarely called for, and are generally restricted to some cooling 
lotion scantily used so as not to wet the permanent dressing, lead and 
opium, and the ice-bag. The latter must be used cautiously because of 
the risk of causing local sloughs, or, according to some authors, of retard- 
ing the repair of the fracture. The blisters which appear so frequently 
on the surface of the limb need only to be pricked and protected from 
chafing by adhesive plaster or flexible collodion. 

Medicinal treatment is directed only to the general condition of the 
patient and guided by such indications as may arise. Phosphate of lime 
is occasionally given with the idea that it favors the consolidation of the 
callus by supplying the needed earthy matters, and some cases and experi- 
ments have been published as demonstrative of benefit obtained by its 
use. It is doubtful, however, if it has any such specific action, or any 
value except as an antacid and absorbent. It is furnished in sufficient 
quantity in ordinary food, and any excess is rapidly eliminated through 
the kidneys. 1 

Compound Fractures. 

The treatment of compound fractures comprises two indications : the 
repair of the fracture, and the healing of the wound. The first is met 
in the same manner as after simple fracture, by reduction and retention, 
the means employed varying only so far as is necessary to make them 
compatible with the proper treatment of the wound. It is the latter, of 
course, which gives this class of fracture its especial importance and 
dominates the treatment, and which has made compound fractures the 
type of severe surgical injuries and the basis of statistics collected to 
determine the merits of contrasted methods of treating wounds. 

Fractures may be compound from the beginning, or they may become 
so by the occurrence of suppuration, the extension of a coexisting wound, 
or the formation and fall of an eschar. The accepted rule of practice is 
to treat all fractures w T ith contiguous and possibly connecting wounds as 
if they were compound, and to avoid explorations of the wound whose 
sole object would be to determine their communication or non-com- 

1 See Midriu, These de Paris, 1877, No. 96, Du phosphate de chaux dans les frac- 
tures. 



186 TREATMENT OF FRACTURES. 

munication with the fracture. The treatment of eschars due to pressure, 
contusion, or extravasation should be such as to delay their separation, 
if possible, until granulations shall have formed upon the broken surfaces 
of the bone and sealed its canals. Verneuil and Marchand 1 report an 
interesting case of this character, though not associated with fracture ; 
the skin of the thigh, covering an enormous extravasation of blood com- 
ing probably from the ruptured popliteal vein, was contused at several 
points and showed numerous small gray eschars still adherent to the 
underlying parts. These eschars were painted twice a day, sometimes 
with tincture of iodine, sometimes with a solution of perchloride of iron. 
This treatment delayed their separation until the extravasation had been 
almost entirely absorbed.. 

Slight, clean-cut wounds that are capable of healing by primary union, 
especially such as have been caused by the projection of the sharp end 
of a fragment, must be treated with the view of favoring this result, 
and it can often be obtained' by simple measures, such as- the application 
of a suture or an occluding dressins;. A favorite method of the English 
surgeons a century ago, and one which is still occasionally employed, is 
to cover the. wound with a pledget of lint soaked in the patient's blood ; 
if all goes well it dries-, and the wound' heals under it as under a scab. 
Or strips of muslin, gold-beater's skin, oil-silk, or thin rubber tissue 
should be clipped in flexible collodion and laid- obliquely across the 
wound, each strip crossing' the preceding one at right angles and over- 
lapping about one third of the preceding- parallel one, just as a wound is 
strapped with adhesive plaster.- This is a better method than simply 
covering the wound with a square piece of the same material dipped in 
collodion. If serum accumulates under the covering it may be let out 
through a puncture made with a needle, and the opening closed with 
another strip. 

Simply covering tlie wound with a few folds of lint soaked in the com- 
pound tincture of benzoin is said, by Mr. Fergus M. Brown, 2 to have 
yielded good results. He recommends it especially for country practi- 
tioners, who "are at a loss for some remedy for wounds which will 
obviate the necessity of going every day long distances to dress trifling 
injuries." A compound fracture^ however, is not - a trifling injury. 

If the wound is so large or so contused' that primary union is not to 
be hoped for, it should be treated systematically and thoroughly in ac- 
cordance with the modern principles of the treatment of surgical wounds. 
First among the various methods by which these principles are carried 
into practice I place unhesitatingly the Lister, method, and next in order 
the method of " through drainage," introduced by Prof. Markoe, and 
Guerin's cotton dressing, of which latter, however, my experience is 
limited to its use after amputations, excisions of joints, and osteotomies. 

The wound and the fracture require certain attentions before the 
dressing is applied. Reduction must, of course, be made as after simple 
fracture, and this is sometimes made exceptionally difficult by the pres- 
ence of a complication, the projection of a fragment through the skin. 

1 Dictionnaire Encyclopedique des Sciences Medicales, article, Contusion, p. 150. 

2 Lancet, July, 1880, p. 9. 



TREATMENT OF FRACTURES. 187 

If extension and counter-extension, aided by pressing- the skin upwards 
or downwards, do not suffice, the wound must he enlarged. freely and, if 
necessary, the muscles divided under it- This, as a rule, is better than 
cutting off the end of the bone, for the sides of the- incision can be 
brought together again by sutures, and its prompt union may be con- 
fidently expected : under antiseptic, treatment. 

The seat of fracture may also be cautiously explored with the finger 
for the purpose of removing totally detached splinters or foreign bodies. 
Splinters adherent to the soft parts must not be torn away ;. it has 
already been shown (page 121),that they will probably retain* their vital- 
ity and perforata valuable part in the consolidation that is to follow. 

If the tendency to displacement is such that it cannot be successfully 
opposed by the retentive dressings at command, it may occasionally be 
desirable to fasten the ends of the fragments together by a suture or 
ligature. This device 1 ' finds its most common use in. operations for the 
cure of pseudarthrosis, but it is also occasionally used in fractures of the 
long bones,. and quite recently, in the bold extension which the success 
of the Lister dressing has given to operative surgery, has been employed 
even in simple fractures of the patella and olecranon. The most per- 
sistent, if not the earliest, advocate of its systematic use appears to have 
been Lerenger-Feraud, 2; but even he finds it most frequently indicated in 
cases of delayed union. It does not seem probable that its use at an 
eaily period w T ould ever be necessary except in some oblique fractures of 
the tibia or humerus, marked by a strong tendency to displacement. 
After having enlarged the wound, if necessary, and exposed the bone 
the lig ture is- applied by passing it under the fragments with the aid of 
a curved, blunt needle or probe, and then twisting it tightly, if of metal, 
or tying it, if of silk, about them after reduction has been made. The 
suture is applied.' by drilling, small holes at corresponding points in the 
fragments, passing a wire or thread through, and fixing it as before. If 
the fracture is sufficiently oblique the ligature holds the bones more 
firmly than the suture, and is not liable to cut or break out as the latter 
is, but its application is likely to require a more extensive denudation of 
the bone. Another method mentioned by MacCormac s 'is to transfix the 
bones with a needle and apply the wire in a figure of eight about its ends. 

1 Norris (Am„..Journ. Med.. Sciences, January, 1842) has been quoted to the effect 
that Hippocrates practised this in recent fractures, and that Horeau applied the same 
procedure to ununited fracturesdn 1805, hut the quotation is inexact and incomplete. 
Norris says Horeau did not originate the idea ; it was practised before him by Icart, 
who bound the fragments closely together by a metallic ligature tbrown around them. 
Dr. J. Kearny Rodgers, of New York, appears to have been the first (1825) to use 
the suture in ununited fracture of a long bone. Hippocrates only tied the teeth 
together after fracture of the lower jaw. Berenger-Feraud (loc cit. infra), depending 
upon an incorrect translation of Hippocrates, states that he sutured the bones directly, 
but the error has been clearly demonstrated by Letenneur in the Union Medicale, 
1870, p. 949, by the aid of the original text. Littre's translation of the disputed 
phrase (vol. iv. p. 149) reads as follows : "La coaptation opSree, on attache les dents 
ensemble, comme plus haut ; cela contribuera grandemeht a l'immobilite, surtout si 
on sait les attacher regulierement, nouant les bouts des fils comme ils doivent etre 
noues." 

2 Bull, de l'Academie de Medecine, 1865, vol. xxx. ; Gaz. Hebdomadaire, 1867, pp. 
610, 624, and 629 ; and several subsequent papers. 

3 Antiseptic Surgery, 1880, p. 198. 



188 TREATMENT OF FRACTURES. 

By withdrawing the needle the wire is liberated and can then be easily 
removed. Some of the other devices used in pseudarthrosis, such as 
fixation of the fragments by a gimlet, an ivory peg, or an iron nail 
driven through them, might be also employed in recent fracture. 

It is the usual practice to bring out the ends of the wire through the 
wound and to remove it after the lapse of from two. to four weeks by 
untwisting it and drawing upon one end, for although the wire may, 
if cut short, become encysted, yet if it should keep up suppuration its 
removal would then be difficult, or at least more troublesome. 

The Antiseptic (Lister) Method. — Mr. MacCormac 1 says : " In no 
kind of surgical injury have the results accomplished by the antiseptic 
method been more thoroughly satisfactory and complete than in com- 
pound fracture. In future we may expect to save the limb of the pa- 
tient in all cases in which the extent of damage to the soft parts, vessels 
and nerves, is not such as to absolutely forbid the attempt. Even in 
cases where the expectation of saving the limb is not great, we are justi- 
fied in giving the patient the benefit of the doubt, as we do not endanger 
his life by so doing ; and should gangrene or any necessity for operation 
occur, Ave may then amputate without increased risk." 

As this asserted superiority is denied by some, and the denial sup- 
ported by reference to occasional unfavorable results, it seems proper 
that the details employed by the strong partisans of the method, those 
who assert its superiority unequivocally as evidenced by the results they 
obtain, should be fully understood, and I shall therefore give at first the 
rules laid down by MacCormac and Lucas-Championniere, 2 the latter 
being the recognized exponent of the theory and practice in France, and 
then indicate various modifications employed by others. 

The materials needed are carbolized gauze, 3 mackintosh or oil-silk, 
drainage tubes, and two solutions of carbolic acid in water, of the 
strength of 1 in 40 and 1 in 20. The portion of the limb that is to be 
enveloped in the dressing is first well washed with soap and water, and 
then with the stronger solution. An anaesthetic is usually used, because 
the manipnlations are often painful and protracted. 

In cases seen shortly after the receipt of the injury the wound must 
be thoroughly irrigated with the weaker solution ; in those that have 
been exposed for several hours the strong solution is used. If the ex- 
ternal wound is too small to allow complete irrigation, it must be en- 
larged, for this disinfection of the cavity is asserted to be the most 
important part of the practice, and one or more counter-openings may 
need to be made in order that it may be thoroughly well done. For 

1 Antiseptic Surgery, 1880, p. 180. 

2 Chirurgie Antiseptique, 2d ed. Paris, 1880. 

3 If the prepared gauze cannot be obtained it can be made when needed by saturat- 
ing a loose-meshed cotton fabric (cheese-cloth, for example) with Von Brun's solution 
and drying it. This solution is : — 

Carbolic acid, ..... 100 parts 

Castor oil, 80 " 

Alcohol or benzine, . . . 2000 '' 

Resin, . . . . . . 400 " 

The resin is first thoroughly dissolved in the alcohol or benzine, and then the others 
added to it. 100 parts of glycerine may be substituted for the castor oil. 



TREATMENT OF FRACTURES. 189 

this washing a syringe is used, and when the fracture is not well exposed 
the liquid should be injected through a soft rubber catheter, the point of 
which is moved to the different parts of the cavity. When the wound 
cavity is large and has been exposed for some hours before the treat- 
ment is begun, or when foreign bodies have been forced into it, the wash- 
ing must be continued for fifteen or twenty minutes with the strong solu- 
tion ; or a still stronger one, 1 part of carbolic acid in 5 parts of alcohol, 
may be used. Attention must be paid to the free escape of the liquid 
during injection, the cavity must be irrigated, not much distended, and 
the last mentioned solution must be used cautiously and gently, for it is 
caustic. If suppuration has begun and granulations have formed, the 
cavity of the wound should be scraped with a curette, or an eight or 
ten per cent, solution of chloride of zinc may be used first and then 
followed by the carbolic acid. 

In some of the slighter recent cases, as of the leg with perforation of 
the skin by the end of one fragment, it may be proper to try for primary 
union, but as a rule drainage tubes should be used, always when the 
wound is large or unclean, or when the bleeding cannot be completely 
checked. Counter- openings are made to facilitate the first washing and 
the subsequent drainage. It is undesirable to pass the drainage tube 
between the fragments of the bone when this can be avoided, but in the 
cases in which it has been done it does not seem to have caused necrosis 
or to have interfered with union. 

Loose fragments and foreign bodies are removed, but projecting points 
of bone should not be cut away unless they actually interfere with the 
setting of the fracture. 

After the disinfection, arrest of bleeding as far as possible, and inser- 
tion of the drainage tubes, the incisions are brought together with sutures, 
pads of gauze or carbolized jute placed to make pressure and prevent 
burrowing, and the gauze dressing and splints placed over all. The dress- 
ing will probably need to be changed the next day and on the third, on 
account of its saturation with blood or the free serous discharge of the 
first hours, but afterwards it may usually be left in place for several 
days. It is seldom desirable to leave the drainage tubes in for more 
than a week, and as a rule they may be removed whenever the dressing 
has remained unstained for two days. 

I have met with no account of the use of Neuber's bone-drains and 
permanent dressings in compound fracture, but should think the elastic 
pressure he recommends would be as useful in these cases as it is after 
operations. 

The most useful form of retentive apparatus in most instances is the 
plaster splint, so constructed that it can be applied and removed without 
damage to it, or an interrupted plaster dressing. A fenestrated 
plaster case does not give sufficient room for the gauze dressing. A 
convenient form of splint recommended by MacCormac for compound 
fracture of the leg has been already described in connection with figures 
100, 101, and 102. When the wound is on the anterior surface, as it usu- 
ally is, the posterior splint can be easily arranged so as rarely to require 
removal. It should be made comparatively narrow, narrower than that 
shown in figure 100, lined internally with mackintosh or oil-silk, over which 



190 TREATMENT OF FRACTURES. 

is placed a layer of folded carbolized gauze. This is placed directly 
upon the leg, the gauze dressing laid upon the wound, and both secured 
by turns of a roller (fig. 117). The anterior splint is then made and 
fixed with another roller. When the wound is to be dressed the anterior 

Fig. 117. 




Compound fracture. Lister dressing and plaster splint. 

splint and gauze are removed, the leg remaining undisturbed in the pos- 
terior splint, out of which, however, it can be lifted if need be. In like 
manner, when the wound is on the posterior surface the anterior splint is 
the permanent one. 

In my opinion, the use of the spray is not essential to the success of 
this method of treating a wound. The irrigation supplies its place at the 
first dressing, and in the subsequent ones a hand spray may be used, or 
a sponge saturated with the carbolic solution squeezed over the wound 
and the mouth of the tube, or a strip of rriuslin wet with the same solu- 
tion laid over them. Inability to obtain a steam atomizer is therefore, 
in my judgment, not a sufficient reason for not resorting to the method. 

A device suggested and employed successfully by Yerneuil 1 may- be 
used, especially in cases where the wound is small and a drainage tube 
is not considered necessary. After disinfecting the wound and the ad- 
joining surface he covers it with a piece of oil-silk three or four inches 
square fastened to the skin on three sides by collodion ; the dependent 
side is left unattached, and the gauze dressings are applied as usual. 
The blood and secretions of the wound make their way out to the free 
edge of the oil-silk and are there absorbed by the gauze. When the 
dressing is changed the oil-silk is not disturbed, its free edge is washed 
and the new dressing applied. Or if antiseptic gauze is not attainable 
layers of muslin wet with the carbolic solution and covered with cotton 
and oil-silk may be substituted. The small square of oil-silk protects 
the wound from contact with the acid, and healing goes on under it un- 
checked. It should, however, be painted over with collodion to make it 
more resisting, or should be double. 

" The " through drainage" proposed by Prof. Markoe 2 has furnished 
excellent results. It is based upon the theory that the benefits ob- 
tained by the use of carbolic acid are due as much to its topical action 
upon the tissues as to its power of preventing decomposition. The 
method has been extensively and successfully employed at the New York 

1 Memoires de Chirurgie, vol. ii. 1880, p. 271. 

2 Am. Journ. Med. Sciences, April, 1880. 



TREATMENT OF FRACTURES. 191 

and Bellevue Hospitals during the past year and a half (1881). One 
or more counter openings are made, perforated drainage tubes passed, 
and injections of a 2J per cent, solution of carbolic acid in water made 
three or four times daily. The wounds are covered usually with a thick 
layer of antiseptic gauze through which the ends of the tubes project, 
but this is not considered essential, a simple dressing kept wet with car- 
bolic acid being thought sufficient. 

It has been shown, by experiment and clinically, that while the 
contact of carbolic acid with a granulating surface checks suppuration 
it also retards cicatrization, and therefore I prefer to follow the example 
of the pure Listerians and inject the wound only when there is a definite 
reason for so doing, such as putrefaction, excessive suppuration, or in- 
flammation. Still, Prof. Markoe has observed in several cases that the 
injections relieved pain or soreness so markedly that the patients asked 
to have them repeated more frequently. I have heard it charged that 
necrosis was more likely to occur under this than under the Lister treat- 
ment, but have never observed any facts that substantiated the charge. 
I have used it a number of times in old fractures with large freely sup- 
purating cavities and inflamed borders, and in some severe recent ones with 
much oozing, and have always been satisfied with the results. I recall 
one case in particular, a severe compound fracture of the lower third of 
the leg with a projecting fragment and large lacerated Avound. It was first 
seen upon the fourth or fifth day when the patient presented a most un- 
promising outlook, with sub-delirium, a dry tongue, and a temperature 
of 104° ; the limb was much swollen, the wound fetid, and its edges in- 
flamed and boggy for a considerable distance. Drainage tubes were 
passed to either side of the leg and frequent injections made. The 
temperature fell, the wound improved rapidly, and the patient recovered 
without necrosis, although for some time the end of the upper fragment 
was exposed and bare for more than an inch. 

Gruerin , s cotton dressing, which grew rapidly into favor in France in 
1871 in the treatment of amputations and excisions, has been used 
successfully, although more sparingly, in compound fractures. So far 
as can be judged from current publications it now holds a place second 
to the antiseptic method in French hospital practice. The method con- 
sists essentially in the envelopment of the limb in very thick layers of 
cotton batting tightly bound on with a roller bandage and left in place 
for three weeks. The principal objection to it in the treatment of frac- 
tures is the difficulty of securing at the same time efficient contention of 
the fragment. This, however, is of secondary importance when the 
lesions are very grave and the question of amputation is impending ; 
under such conditions the surgeon may be well content to save the limb 
even if its form should be more or less irregular, and, in default of better 
means, the cotton dressing enables him to do this. The thermometer 
may be safely depended upon to give timely notice of complications oc- 
curring about the wound. 

The limb and the wound are first disinfected ; then the entire limb is 
WTapped in successive layers of cotton batting, the thickness of which 
when tightly compressed with a roller bandage is about two inches ; 
reduction is made by extension and counter-extension, and immobility 



192 TREATMENT OF FRACTURES, 

secured by a gypsum, starch, or silicate of soda bandage applied over 
all. Gudrin advises that the uniformity of the compression should be 
further assured by the application of a second roller bandage on the 
second day, and if this is done it must of course precede the hardening 
bandage. 

Verneuil 1 uses a modified form of this dressing which, he claims, as- 
sures a better retention and gives an opportunity for inspection of the 
parts without disturbing the patient. It consists of a Scultetus appa- 
ratus with the addition of an inner layer of broad bands of cotton batting 
corresponding in direction and mode of application to the layer of short 
bands. (See p. lbO.) The thickness of the layer is very much less than 
that of the Guerin dressing, but, according to Verneuil, its efficiency is 
as great. He further covers the wound with a patch of oil-silk as above 
described, and lays over it compresses wet with carbolized water. 

The inflammatory processes that may supervene in the progress of 
the case are met in accordance with the general principles of surgery. 
Pus that has burrowed or formed at a distance must be promptly evacu- 
ated ; it is not necessary to wait for fluctuation when the bogginess and 
tenderness at any point show so clearly what is going on underneath, or 
when a probe can be passed down to the collection through the main 
wound. These abscesses usually communicate with the main cavity, 
and it is desirable that drainage tubes should be passed through from 
one to the other. 

Inflammation about the wound is best controlled, in my experience, by 
the free use of the weaker carbolic solution in frequent injections and 
upon compresses. In fractures of the fingers, hand, or forearm, with 
severe inflammation of the inter-muscular spaces of the latter, I have 
seen much good result from immersion of the limb for several hours in a 
bath of tepid water containing one per cent, of carbolic acid. I usually 
keep it in the bath during the greater part of the day, covering it in 
the intervals and at night with compresses wet with the two and a half 
per cent, solution, and continuing this until the inflammation subsides. 

Prof. Hamilton recommends the use of compresses of sheet lint kept 
constantly wet with water at the temperature of 95° to 100°, or, in 
the case of gangrene, actual or impending, 105° to 110°. 

The use of cold, either by the ice-bag or irrigation, has been recom- 
mended, but the weight of evidence is now against it. Spillmann 2 says 
it is actually harmful in fractures of the arm or thigh, often useful in 
those of the forearm or leg, and " yields marvellous results when applied 
to injuries of the hand or foot." Used upon a badly contused wound it 
will almost certainly cause gangrene In such cases a light well-made 
poultice may sometimes be used with advantage. 

If suppuration is prolonged it may be profuse and undermine the 
patient's strength to such a degree as to render the sacrifice of the limb 
necessary to the preservation of his life ; or it may be slight, the wound 
being reduced to a simple sinus, and the fracture so well consolidated as 
to make the limb useful. Both results are more rare than they were 

1 Loc cit., p. 272. 

2 Diet. Encyclopedique, 4th Series, vol. iv. p. 169. 



TREATMENT OF FRACTURES. 193 

formerly. Sinuses are kept up by caries, necrosis of portions of the 
callus or of splinters, and by foreign bodies introduced at the time the 
fracture was received. When due to caries they may sometimes be 
cured by stimulating injections such as the sulphate of copper or of zinc, 
or Villate's liquid. When due to necrosis or the presence of foreign 
bodies they must be enlarged and the cause removed. This may require 
the cutting away of a portion of the callus, and it should be done thor- 
oughly. The antiseptic method has furnished some rapid and complete 
cures in this class of cases. 

For the treatment of other complications the reader is referred to the 
preceding chapter. 

The same principles and details of treatment, modified somewhat by 
the different anatomical conditions, are applicable to the treatment of 
compound fractures communicating with or involving a large joint. 
The antiseptic method has wrought an even greater change in the treat- 
ment of this variety than in the less complicated ones of the shaft, and 
it is now the rule to save the limb where formerly it was the exception. 
The opening into the joint must be enlarged if necessary, or free incisions 
made to insure thorough disinfection and drainage ; this seems to be the 
capital point in the treatment, for if the case does well it does well from 
the very first, from the moment of the primary cleansing. In fractures 
of the upper extremity with much shattering, the broken surfaces of the 
bone may advantageously be made regular by a formal excision, because 
mobility rather than solidity is sought for; while in the lower limb under 
similar circumstances as much of the bone should be preserved as is pos- 
sible, in order that the support may be solid even if the mobility is lost. 
Oilier 1 has pointed out clearly the change effected by the antiseptic 
method in the indications for resection after compound fractures of joints 
in consequence of their diminished gravity when treated conservatively 
under the Lister dressing. The surgeon can advantageously wait in 
doubtful cases, as Von Langenbeck 2 also showed by his analysis of the 
results obtained after gunshot w T ounds of joints, until the parts shall have 
shown the limit of their ability to repair their injuries unaided, and 
then, if necessary, amputation or secondary resection can be undertaken. 
The experience of both these surgeons has shown that the applicability 
of partial excisions is greater than has been supposed, of excisions, that 
is, in which only a portion of the articular surface is removed, whether 
it be the entire end of one of the members or contiguous portions of both. 
Instead of a formal excision, — that is, of an operation consisting in the 
removal of all free or fissured splinters and the regularization of the 
ends of the bone, — Oilier limits his interference to the removal of foreign 
bodies and completely detached splinters, leaving those that are still ad- 
herent to the periosteum, even if only partially so. The death of a 
splinter is due not so much to the traumatism as to the subsequent inflam- 
mation and suppuration. If these are avoided the splinter preserves 
its vitality as after simple fracture. The main condition of success is 

1 Resections et pansernents antiseptiques, in Revue Mensuelle de Med. and Cliir.. 
1880 pp. 926 and 931. 

2 Archiv fur Klinische Chirurgie, 1874, vol. xvi. 

13 



194 TREATMENT OF FRACTURES. 

that the cavity, and in this term are included all the pouches of the syno- 
vial sac, shall be efficiently drained, and therefore Oilier multiplies his 
counter-openings and drains, and diminishes the number of his sutures. 

Mr. Lister's practice, according to Cheyne, 1 is to enlarge the opening 
freely when it communicates directly with the joint, and to wash out the 
cavity with the 1 in 20 carbolic solution if the wound is seen within an 
hour or two of its receipt, or with the 1 in 5 alcoholic solution if a longer 
time has elapsed, using a gum catheter in order to reach all its recesses. 
If the communication with the joint is through a fissure in the bone, as 
in fracture of the lower third of the femur with splitting of the con- 
dyles, he makes a separate incision into the joint at a point suitable for 
drainage, washes it out, and inserts a drainage-tube at each opening. 

Gunshot fractures owe their special gravity to the shattering of the 
bone and the contusion of the soft parts, conditions which render suppu- 
ration inevitable, and increase the probability of the occurrence of severe 
osteomyelitis. The necessity for the rigorous employment of the anti- 
septic method is therefore all the greater, and experience has shown that 
its results are favorable. Some of these results have been already 
quoted in Chapter II., together with the choice of operation in the inju- 
ries of the different limbs. Sufficient experience, perhaps, has not yet 
been accumulated to show how far conservative treatment may be safely 
carried, but the facts collected from the Holstein, Austrian, and Franco- 
German wars, and so carefully analyzed by Yon Langenbeck, and the 
scattered reports of some army surgeons after the more recent wars, 
prove that in gunshot as in other compound fractures an attempt to pre- 
serve the limb may be made under antiseptic precautions, without increas- 
ing the risk to the patient's life, if prompt recourse is had to secondary 
amputation or excision when the indications for them appear. It seems 
not unlikety that when the bone is covered by thick layers of muscle, as 
in the thigh, Prof. Markoe's method of " through drainage" with fre- 
quent injections would be especially useful in the first week by promptly 
removing the gangrenous shreds cast off from the sides of the wound, and 
by assuring an asepticity which, perhaps, could not be obtained by a 
single irrigation at the first dressing. 

Immediate amputation after compound fracture is indicated when 
there exist in addition injuries to the main bloodvessels which make the 
preservation of the limb impossible, or to the nerves which would render 
it useless, or to the soft parts so extensive, or in such positions, that the 
cicatrix would create a disability greater than that of the loss of the 
limb, or when the bone is literally smashed over a great extent and the 
neighboring joints are involved. 

Secondary amputation finds its indications in profuse and prolonged 
suppuration that cannot be checked and that endangers the patient's life, 
or after a failure to keep the wound aseptic and the consequent destruc- 
tion of parts which it had been thought possible to save, or in similar 
conditions in articular fractures when excision is contra-indicated. 

There will always be cases in which the greatest uncertainty and 
anxious doubt will be felt by the surgeon, and this doubt is by no means 

i British Med. Journal, Nov. 29, 1879, p. 859. 



TREATMENT OF FRACTURES. 195 

greatest in those whose experience is the least extensive, since a single 
failure may leave a painful impression, or have a weight that many suc- 
cesses cannot remove, or entirely overcome. But, in consideration of its 
importance, I may repeat that we have in the antiseptic method a means 
of safely postponing the decision in these doubtful cases, of giving the 
patient the chance, and waiting until he has shown his ability or his 
inability to profit by it. 

If amputation is considered necessary immediately after the accident 
it should be performed without delay, for all are agreed that the dangers 
of the operation are increased by the necessity of cutting through the 
inflamed tissues of a feverish patient. Experience has also shown that, 
the period for immediate amputation having passed, it is better to wait 
until suppuration has become fairly established and the general reaction 
and acute inflammatory condition of the parts have subsided. But this 
is not to be taken as a fixed and inflexible rule, for many surgeons hold, 
and with apparent reason, that although the results of late, secondary, 
amputation are statistically better than those of amputation performed 
during the acute inflammatory period, yet many patients whose opera- 
tions are postponed succumb before the period considered fit for the ope- 
ration has been reached, and this mortality should be added to that of 
the secondary amputations in making the comparison. Instances are not 
lacking in which amputation, under conditions which made the preserva- 
tion of the patient's life in either case apparently hopeless, has resulted 
successfully. 

In conclusion, I may quote some of the sentences w T ith which a surgeon 1 
of large experience terminates his consideration of this subject. "This 
question," he says, " of the propriety of amputation is one of the most 
difficult which the surgeon has to solve, and it is impossible to state cate- 
gorically what cases need it, and what cases can recover without it. In 
doubtful cases I lean always towards preservation of the limb, and while 
recognizing that primary amputations are less dangerous than secondary 
ones, I prefer to take the chance of saving the limb. But when it be- 
comes clear that all hope of doing this is lost, I do not allow myself to 

be stopped by the gravity of the situation I believe one is 

justified in amputating so long as purulent infection (pyaemia) has not 
actually taken place. The cases quoted, and the number could be in- 
creased, prove this sufficiently. . . . Finally, we may be called upon to 
amputate to protect the patient from the consequences of suppuration 
and hectic fever. At what period should the decision be made ? Upon 
this point I can say nothing positive. Each case presents special indi- 
cations. The only recommendation I can offer is not to wait until the 
patient is completely exhausted by the suppuration." 

I append also a few of the late Prof. Cowling's " Aphorisms on Frac- 
tures " because they present the ideas in a compact and easily remem- 
bered form: — 

" With the improved methods of treatment the danger to life and limb 
in compound fracture has been reduced to such an extent that former 
laws for determining the question of amputation are to be recast." 

1 Valette, in the Diet, de Med. et Chir. Pratiques, article, Fracture, p. 502. 



196 TREATMENT OF FRACTURES. 

" The best time to dress any fracture is immediately after its occur- 
rence." 

" Temporary dressings are only to be used when the materials for 
permanent dressings are not to be obtained, or for the purpose of moving 
the patient." 

" The indications for treatment of fracture are, first, reduction of the 
fragments of bone, second, their immobilization." 

" Perfect immobilization is only to be obtained when the joints con- 
tiguous to the fracture are secured; and there is no law more important 
than this in fractures of the lower extremity." 

" One of the commonest reasons for the failure and disaster in the 
treatment of fracture arises from the fact that bone and muscle only are 
considered, and bloodvessels and nerves are left out of sight." 

" Carved and manufactured splints generally fit nobody, and are to be 
rejected as not only expensive but damaging. Deal board, pasteboard, 
and the materials for the plastic apparatus form all the appliances needed 
by the surgeon." 

" The application of a bandage immediately to the skin, whether as a 
protection or to prevent muscular spasm, has resulted in such disaster, 
that it is one of the curiosities of surgery how it could be repeated at 
this day. When cotton is placed over such a bandage it forms an ab- 
surdity scarcely credible in a man of ordinary sense." 

" Comfort is the sign that a fracture has been properly dressed. . . 
The general law is that pain should speedily subside when the dressings 
are not at fault." 

" Frequent dressings of fractures for the purpose of examination are 
not only useless but hurtful." 

" Whenever it is possible, after the dressing of a fracture, it should 
be seen again in a few hours, and the case should receive daily attention 
in its earlier stages." 

" The surgeon is to regard not only the welfare of his patient, but his 
own reputation. To this end he ought to give fair warning of possible 
ill results. . . . There is one thing which the law is slow to excuse 
—neglect." 



PSEUDARTHROSIS AND DELAYED UNION. 197 



CHAPTER IX. 

PSEUDARTHROSIS AND DELAYED UNION. 

In a relatively small number of fractures of the shaft of long bones 
it is found on examination of the limb at the expiration of the period 
which is usually sufficient for the completion of repair that the frag- 
ments are still movable upon each other. The degree of this mobility 
and the length of time during which it persists are variable. When it 
is slight and but a few weeks or months have elapsed since the injury 
was received, it is usually spoken of as delayed union ; when more free 
and painless, and when several months have passed the condition is de- 
scribed as a pseudarthrosis. The distinction has an important practical 
value, for it has much weight in determining the choice of a method of 
treatment; union that is simply delayed will often become complete, that 
is, the existing soft callus will complete its natural evolution by ossify- 
ing, by the aid merely of a dressing that immobilizes the parts, while a 
pseudarthrosis can be overcome only by operative measures of greater 
or less severity. 

Delayed union that does not terminate in pseudarthrosis causes but 
little inconvenience beyond the prolongation of the treatment, but pseu- 
darthrosis may result in a disability so complete that amputation of the 
limb is sought as an amelioration. This is rare, and is found only in 
the lower extremity ; pseudarthrosis of either the arm or forearm can be 
sufficiently controlled by mechanical appliances to enable the patient to 
make good use of the limb, and even in some cases the abnormal mobility 
is so slight that no additional support is needed. 

Fibrous union of a fractured short spongy bone or the expanded ex- 
tremity of a long one, or between an apophysis and the bone from which 
it has been torn is not usually spoken of as pseudarthrosis, and, as has 
been elsewhere shown, is a common result after fracture of the patella 
and of apophyses to which powerful muscles are attached. 

Norris, 1 who wrote the first elaborate article upon this subject, one 
that has served largely as the basis of most subsequent ones, described 
four varieties of incomplete union, which, however, if differences in 
degree are disregarded, may be reduced to two : 1st, those in which a 
more or less extensive fibrous band, with or without nodules of bone de- 
veloped in it or on the surface of the fragments, unites the latter ; 2d, 
those in which an actual joint with a capsule and cartilaginous surfaces 
is formed by the broken ends. The second form is rare ; the first is the 
common one and presents several important differences in degree. 
Thus, the ends of the bone may be in good position and enveloped in a 

1 Am. Journal Med. Sciences, 1842, vol. xxix. p. 13. 



198 PSEUDARTHROSIS AND DELAYED UNION. 

large callus which lacks only ossification to make the union perfect. It 
is an arrest of the normal process of repair at a comparatively late 
period, may be recognized by the presence of the callus and the pain 
caused in it by communicated movements, and is amenable to treatment 
by simple methods which favor or excite ossification. Or the union may 
consist of a longer or shorter, more or less voluminous bundle of fibrous 
tissue uniting the bones end to end when they have been kept in position, 
or laterally when they have over-ridden. The ends of the bones are altered 
by a formative or rarefying osteitis which produces in the one case 
closure of the medullary canal by a bony deposit, and nodules upon the 
surface, in the other the absorption of prominent points and angles, and 
the reduction of the ends to conical points. In a remarkable and ex- 
ceptional case quoted by Norris from the Boston Medical and Surgical 
Journal, July 11th, 1838, p. 368, a lad, 18 years old, broke his right 
humerus near its middle ; while repair was apparently progressing favor- 
ably he fell and again broke the arm at the same place. This time the 
fragments not only failed to unite but disappeared gradually by absorp- 
tion until all the bone between the shoulder and the elbow had disap- 
peared. When last seen, eighteen years later, the arm hung loose from 
the shoulder and could be twisted twice completely around without pain. 
On traction it would extend to a length equal to that of the other, and 
then if released would immediately shorten about six inches. 1 Agnew 2 
refers to a case under his own observation in which half the humerus 
had disappeared in eight years after fracture. Gurlt quotes a some- 
what similar case reported by Peacock. 3 A lad, 18 years old, had a 
pseudarthrosis of the femur that had lasted ten months and was then 
treated unsuccessfully by resection. Three months later the limb was 
amputated on account of prolonged suppuration and hectic fever. It 
showed serous infiltration of the connective tissue, marked atrophy of 
the muscles and especially of the bone which consisted of little more 
than a shell one-tenth of an inch thick at the thickest part. The lower 
fragment was even thinner, and where the two fragments were in contact 
the spongy tissue had been entirely absorbed. The atrophy involved 
the entire lower end of the bone, which could be easily cut with a knife. 
The tibia, fibula, and bones of the foot were softened, and their compact 
tissue had been in part replaced by marrow. 

The mobility in these cases of fibrous union depends upon the length, 
number, and position of the connecting bands. When the fragments 
override for a considerable distance, as in a fine specimen of ununited 
fracture of the upper third of the femur, which is preserved in the Belle- 
vue Hospital Museum and was taken from a patient at one time under my 
care, and are supported by contact with, and fibrous attachments to, 
bony prominences the mobility will be very slight and the limb, perhaps, 
useful ; when, on the other hand, they are end to end and the union 
consists only of slight fibrous bands, or even of merely a fibrous thick- 
ening of the adjoining muscular layers, the mobility may be very free. 

1 The man died at the age of 70, and the report of the autopsy is given in the 
Boston Med. and Surg. Journal, October 10th, 1872. 

2 Surgery, vol. i. p. 746. 

3 London Med. Gazette, 1838-39, vol. ii. p. 847. 



PSEUDOARTHROSIS AND DELAYED UNION. 199 

In the other form an actual joint is formed, the ends of the bones are 
more or less enlarged by new deposits, rounded and smooth, and covered 
entirely or in part by cartilage. They are united by a complete periph- 
eral capsule and moistened by a liquid resembling synovia. The por- 
tions of the contiguous surfaces not covered by cartilage are eburnated 
and made smooth by friction upon each other. Although I have met 
with no recorded case in which it is distinctly stated that the cartilagi- 
nous character of the tissue covering the ends of the bones was deter- 
mined by microscopical examination, and although it is known that 
wounded cartilage repairs itself usually by fibrous tissue, yet I believe the 
tissue to be real cartilage, in some cases at least, because it has been de- 
monstrated to be so in one case 1 of false joint established intentionally by 
operation, and because, as we have seen, the callus is cartilaginous during 
one period of its development. It seems justifiable to assume that por- 
tions of this cartilaginous callus may persist and remain as articular car- 
tilage just as portions remain in the normal embryonal formation of 
bones and joints. An additional point of resemblance to normal joints 
is found in the loose cartilages which are occasionally found within 
these joints of new formation. A specimen of this kind is pictured in 
the first volume of Holmes's System of Surgery. Grurlt 2 collected five 
cases of this form of pseudarthrosis in the arm, three in the forearm, 
and two in the thigh, verified by post-mortem examination. 

Pseudarthrosis is not easily produced intentionally in animals, but 
Breschet succeeded in obtaining six specimens which showed distinct 
cavities with capsular ligaments and synovial liquid. The synovia appeared 
at the latest on the twenty-seventh day, and the older the fracture the more 
had the walls of the cavity lost their pink color, and become smooth and 
polished on the inside, and showed externally the appearance of fibro- 
cartilage. The eansule surrounded the broken ends and was continuous 
with them. In some cases he found the broken surface of an opaque, 
white color, glistening like synovial membrane, and covered by tissue 
resembling articular cartilage. A period of eighty-five days was suffi- 
cient for the production of this condition in a dog. 

The different statistics and estimates that have been published con- 
cerning the frequency of failure of union as compared with the total 
number of fractures vary within wide limits, but all agree in making it 
small. The following are taken from Norris, Gurlt, and Agnew : Pier- 
son found only 1 case in 367 fractures treated in the Massachusetts Gen- 
eral Hospital ; Lonsdale only 5 or 6 in 4000 fractures treated in the 
Middlesex Hospital in London ; Stanley remembered none in sixteen 
years at St. Bartholomew's Hospital in London, and Mr. Callender 3 says 
that in the seven years ending in 1867 there had been treated in the 
same hospital 2376 fractures, exclusive of those of the upper extremi- 
ties, and " with the exception of certain fractures of the patella and 
neck of the thigh bone there had been but one case of non-union." 
There was none in 916 cases of fracture treated in the Pennsylvania 

1 Sayre's Orthopedic Surgery, 1876, p. 442. 

2 Loc. cit., p. 592. 

3 Med. Chir. Trans., vol. li. p. 148. 



200 



PSEUDARTHROSIS AND DELAYED UNION. 



Hospital between 1830 and 1839, and Agnew says he could learn of 
none among the 6480 fractures treated in the same hospital between 
1850 and 1874. Amesbury alone speaks of it as " by no means un- 
common," and places his personal experience at 56 cases. The conclu- 
sion to be drawn is that it is exceptionally rare under proper treatment, 
and that when it occurs under such circumstances it is generally due to 
a definite, recognizable cause independent of the treatment. 

The cases contained in the tables of Norris, Gurlt, and Agnew are 
divided as follows among the different bones : — 



Femur .... 
Leg (one or both bones) . 
Humerus . 
Forearm (one or both bones) 



Norris (1842). 


Gurlt (1S61). 


48 
33 
48 
19 


33perct. 
22 " 
32 " 
12 ^ 


132 
131 
165 

50 


27perct. 
27 " 
34 " 
10 "' 


143 




478 


. 



Agnew (1S7S). 

155 24perct. 

180 '28 " 

219 J34 " 

76 12 " 



630 



I presume that all of Norris's cases are included in both the other 
lists, and probably most, if not all, of Gurlt's are included in Agnew's, 
therefore the three lists cannot be added together to make a grand total. 
Furthermore, these figures do not represent an equal number of cases, 
for many of the cases appear several times in each list under the different 
methods of treatment. It will be noticed that the percentages of Gurlt's 
and Agnew's correspond yery closely, and that in them the pseudarthro- 
ses of the humerus are the most numerous, and those of the forearm the 
fewest. By reference to the general statistics given in Chapter I. it 
may be seen that fractures of the humerus are relatively few when com- 
pared with those of the other large bones of the extremities, and conse- 
quently the percentage of the cases in which union fails after fracture 
of the humerus is much greater, even in comparison to others, than the 
above lists indicate when taken alone. Agnew's list contains 3T cases 
of non-union of both bones of the forearm, 23 of the radius alone, and 
16 of the ulna alone ; 94 of both bones of the leg, 84 of the tibia 
alone, and only 2 of the fibula. 

Gurlt's analysis shows the same preponderance of pseudarthrosis as 
of fracture in males, and the greatest frequency of both between the 
ages of 20 and 30 years ; but, on the other hand, an important difference 
in childhood. While his general statistics show that fractures are almost 
as frequent in the first ten years of life as they are in the third decade, 
during which they are more frequent than in any other, the proportion 
of pseudarthrosis in the same periods is only as 1 to 8. This rarity of 
non-union in childhood is doubtless due to the vigor of the healing pro- 
cess at that age. His statistics show further, in contradiction of a rather 
widely held opinion, that advanced age is not unfavorable to repair, and 
that, all things considered, non-union is more common in the prime of 
life than at any other period. Norris claimed, on the strength of re- 
corded observations and daily experience, that advanced age was not to 
be considered among the causes of non-union, and quotes some cases in 
which union took place within the usual time in very old patients. 



PSEUDARTHROSIS AND DELAYED UNION. 201 

The causes of delay or failure of union are general and local, those 
which lie in a constitutional vice or temporary deterioration of the con- 
dition of the patient, and those which lie in the fracture itself or the 
associated injuries. These causes may act simultaneously or separately, 
and, as may be inferred from what has been said concerning the rarity 
of this result, are by no means certain to produce it in any given case 
in which they may be operative. The repair of a fracture requires a 
special productive effort on the part of the injured tissues, and, as is seen 
occasionally after injury of other parts, the resources of the organism 
are sometimes insufficient to meet the demands made upon them ; the 
local causes are usually mechanical. 

The general causes to which the occurrence of pseudarthrosis has been 
attributed in different cases are tabulated by Gurlt, who follows Xorris 
in this quite closely, as follows : — 

1. Syphilis. 

2. Pregnancy. 

3. Physical deterioration. 

a. Due to a drain upon the system (hemorrhages, lactation). 

b. Due to general debility (especially from insufficient nourish- 

ment). 

4. Advanced age. 

5. Severe acute diseases (typhoid fever, variola, etc.). 

Of each of these except the fourth he quotes a few instances, but 
couples them with others to show that the influence is a slight one. 
Of the fourth he quotes only cases to show that prompt union is possible 
in very old people, and refers to the statistics already given to prove 
that the frequency of non-union is not disproportionately large in old age. 

Of the local causes the same may be said as has just been said con- 
cerning the general ones ; any one may prevent or delay union, but 
none will certainly do so. Some act mechanically, some by change in 
the blood or nerve-supply of the parts, others by modifying the produc- 
tive process either directly by disease in the broken ends of the bones, 
or indirectly by inflammation of the surface of the limb. They may be 
divided as follows for detailed consideration : — 

1. Unfavorable relations or conditions of the fractured parts. 

2. Interposition of a foreign body. 

3. Defective innervation. 

4. Defective blood-supply. 

5. Disease of the bone. 

6. Inflammation on the surface. 

7. Defective treatment. 

1. The unfavorable relations or conditions of the fractured parts con- 
sist in separation of the broken surfaces by over-riding or extreme lateral 
displacement of the fragments, and loss of substance by splintering, re- 
section, or necrosis. Lack of contact between the broken surfaces is 
the most frequent cause of non-union, and it is observed not only when 
the ends of the fragments are separated longitudinally, but also when 
the line of fracture is oblique and one of the fragments has the constant 
tendency to lateral displacement which has been mentioned elsewhere 
as common in some fractures of the tibia. Not only does the actual 



202 PSEUDARTHROSIS AND DELAYED UNION. 

separation act unfavorably, but the mobility, which alone allows the 
separation to take place after reduction has been made, adds another 
obstacle to union. Loss of substance due to partial necrosis of one or 
both fragments is less likely to cause non-union than loss of substance 
due to comminution or resection, because in, the former case the perios- 
teum of the necrosed portion is more likely to preserve its position and 
to be stimulated to produce rapidly a shell of new bone to take the place 
of the sequestrum as soon as the latter is removed. 

2. Foreign bodies introduced from without, such as bullets or portions 
of the tissues of the limb, splinters, muscles, or tendons, and possibly 
even blood-clots may delay or prevent union by occupying the space which 
would otherwise be filled by the callus. Splinters of bone, as we have 
seen, usually preserve their vitality, or, even if dead, may become firmly 
imbedded in the callus, and serve to strengthen the union in simple frac- 
tures. In compound fractures which suppurate they may die and then 
act like a foreign body introduced from without. Portions of muscle are 
liable to become interposed only in fractures accompanied by considerable 
displacement and laceration of the soft parts, and when, the fracture 
being very oblique, the sharp end of one fragment has been driven into 
the muscle and has not been withdrawn. Gurlt thinks this complication 
is probably comparatively common, and is the cause of many of the 
slight delays noticed in consolidation. The examination of various spe- 
cimens has shown that muscular bundles thus interposed atrophy by dis- 
use or pressure, and may disappear entirely. Collections of blood are 
thought by some to act in a similar manner, but the study of the normal 
process of repair and clinical observation of some cases of fracture com- 
plicated by traumatic aneurism indicate that the obstacle thus created 
must, if it exists at all, be very slight. Granulations penetrate a soft 
clot very readily, and hasten its absorption, and it is even claimed in 
some quarters, although improperly in my opinion, that the clot is capa- 
ble of producing new tissue within itself, and without extraneous aid. 
The observations which have led to this belief show at least that the 
clot is not an obstacle to repair, either of soft parts or of bone. 

3. Defective innervation. It has been repeatedly asserted and de- 
nied, and both opinions supported by the citation of cases, that injury 
to the nerves supplying a fractured limb or to the spinal cord above the 
origin of such nerves impedes or entirely prevents the formation of a 
callus. The disagreement appears to have arisen through a failure to 
discriminate between the paralyses in the different cases, and the same 
error has affected many of the experiments made to elucidate the ques- 
tion. A recent thesis by Bognaud, 1 presents the facts very clearly, and 
shows by clinical and experimental observations that certain portions of 
the nervous system do exercise a trophic influence upon the bones as 
upon other tissues, and that the destruction of the nerves through which 
this influence is conveyed, or of the centres at which it arises, prevents or 
retards consolidation. The most frequent examples are furnished by 
fractures of the lower extremity with concomitant injury to the spinal 

5 Sur 1' Influence de quelques lesions du systeme nerveux sur la formation da cal. 
These de Paris, 1878, No. 370. 



PSEUDARTHROSIS AND DELAYED UNION. 203 

cord. In paralysis due to a lesion limited to the upper portion of the 
cord, the lower segment remaining intact, repair is not interfered with, 
but on the contrary, is rather aided by the immobility and insensibility 
produced by the paralysis. The explanation is found in the supposed 
existence of trophic centres in the lower portion of the cord, from which 
trophic nerves pass in company with the others to be distributed to the 
lower limb. 

Bognaud collected six cases of fracture of the leg, or of the fibula alone, 
with complete paraplegia due to simultaneous fracture of the vertebral 
column at or below the last dorsal vertebra, in which consolidation failed 
entirely to take place ; and he gives others in which, the paralysis being 
incomplete, or the lesion of the spine situated at a higher point, partial 
or complete repair followed. He reports also in full a case which came 
under his own observation of fracture of the humerus in a healthy man 
of 24 years, due to a fall which occasioned also paralysis of all the 
muscles of the same arm, except the deltoid, and almost complete loss of 
sensibility in the limb. Three and a half months afterwards, when the 
record ends, there Avas not the slightest trace of union of the broken 
bone. The fracture had been judiciously treated in hospital, and during 
the last month and a half electricity, first by the interrupted and then 
by the continuous current, had been employed in vain by Broca. 

4. Defective blood supply, the result either of occlusion of the prin- 
cipal artery of the limb, or, more especially, of the relations of the nu- 
trient artery of the bone to the fracture, has been considered a cause of 
non-union. The only case mentioned by the authors, in which repair 
seems to have been retarded by occlusion of the main artery of the 
limb is one reported by Dupuytren, 1 a fracture of the leg in a woman 
aged 62, whose femoral artery he had tied on aceount of a traumatic 
aneurism caused by the fracture. Consolidation had scarcely begun at 
the end of the first month, and was not complete until after the expira- 
tion of four months. On the other hand, there are a number of cases 
recorded in which a similar operation caused no delay, and from our 
knowledge of the rapidity with which the collateral circulation is estab- 
lished, there seems no reason to suppose that the ligature of the main 
artery can have any material influence upon the consolidation. 

A similar conclusion must be reached reo;ardin£ the influence of the 
nutrient artery. Gueretin, and subsequently Norris, collected some 
statistics designed to show the position of the ununited fracture with 
reference to the point of entrance and the direction of the nutrient artery. 
The results were conflicting. Gueretin collected 35 cases of ununited 
fracture, in only 10 of which the injury was situated in the portion of 
the bone towards which the artery was directed ; Xorris collected 41 
cases, in 27 of which the injury occupied that portion. Taken together 
the two lists give 76 cases with 37 fractures on one side of the point of 
entrance of the artery, and 39 on the other. 

The statistics themselves are untrustworthy, as Norris admits, because 
the observations were not controlled by dissection, and the point at which 
the artery enters the bone varies widely. Curling thought he found 

1 Quoted by Malgaigne, loc. cit., vol. i. p. 144. 



204 PSEUDARTHROSIS AND DELAYED UNION. 

corroborative evidence of the correctness of the claim in an alleged par- 
tial atrophy, after fracture, of the fragment towards which the artery was 
not directed, but Gurlt, who afterwards examined his specimens, declared 
himself unable to recognize any difference between the two parts. As 
the soft parts, and especially the periosteum^ take a much more promi- 
nent part in the formation of the callus than the bone itself does, and as 
their blood-supply is not received through the nutrient artery, and as 
we have learned that even total separation of a splinter does not neces- 
sarily cause its death, the theoretical support of the assertion is no 
stronger than that supplied by observation, and it must be dismissed as 
entirely unproven and improbable. Indeed, an argument based upon a 
supposed inequality in the blood-supply due to the direction of the nu- 
trient artery would justify equally well a conclusion directly opposed to 
the one reached by these writers, for, if the amount of the blood supplied 
to a bone through its marrow varied in the different parts according to 
the direction of the nutrient artery the half which received the less 
amount in this manner would, theoretically, have to receive a relatively 
larger amount through the vessels of the periosteum in order to make good 
the difference, and, thus receiving a larger amount from its surface, and 
less through its central canal, would be less affected by a fracture which 
cut off the latter supply. 

5. Disease of the bone. Any of the diseases which have been men- 
tioned as possible factors in the etiology of the so-called spontaneous 
fractures, syphilis, cancer, hydatid or other cysts, may interfere in like 
manner to delay or prevent consolidation. Gurlt' s table contains four 
such cases, two of hydatids and two of syphilitic exostoses. The com- 
monest cause of this kind, however, is suppuration of the bone maintained 
by a splinter or a necrosed fragment. The influence exerted by the 
presence of such a body may delay consolidation until its removal, or 
may lead to the absorption of a callus already formed and perhaps even 
sufficient to unite the fragments firmly. The removal of the splinter or 
of the sequestrum is usually followed by complete recovery, but in some 
cases permanent pseudarthrosis has resulted. Gurlt quotes the following 
interesting case from Gerdy. 1 In a man whose right arm had been 
broken by a gunshot nine years before and had slowly united, an abscess 
formed at the site of the fracture, was opened, and gave exit to several 
small fragments of bone. It failed to close, the callus softened, and 
notwithstanding proper treatment the bones failed to reunite ; the patient 
became hectic, and the limb was amputated. The bone was found dis- 
tinctly inflamed, spongy, and traversed by vessels. The marrow was 
slate-colored in places, red in others, and suppurating at the points cor- 
responding to the wound. 

6. Inflammation on the surface of the limb. Malgaigne 2 says that 
phlegmons and erysipelas occurring in a fractured limb generally retard 
the solidification of the callus, and he quotes a case that came under his 
own observation of a man who had broken one of his fingers ; a phleg- 

1 Chirnrgie pratique, 3me Monographic, Maladies des organes du Mouvement, Paris, 
1855, 8, p. 126. 

2 Loo. cit., p. 144. 



PSEUDARTHROSIS AND DELAYED UNION. 205 

monous inflammation was set up in the neighborhood of the fracture, the 
callus did not begin to form until after this had subsided, and consolida- 
tion was not complete until after two and a half months had elapsed. 

7. Defective treatment. This includes errors of commission and omis- 
sion. Among the former is reckoned the prolonged use of cold applica- 
tions, and there is every reason to believe that when cold is used in its 
most active and efficient forms, such as bags of cracked ice or irrigation 
through a coil of lead tubing, upon limbs that are not acutely inflamed 
the consolidation of a fracture may be considerably delayed thereby. 
Malgaigne goes much further and accepts the theory, which he traces 
back to the times of Paulus Aegineta and Avicenna, that moist applica- 
tions, hot as w T ell as cold, are injurious. The same charge has been 
made against the method of continuous irrigation of a wound, and in the 
statistics of nine compound fractures treated in this manner collected by 
Nivet 1 it appears that only two consolidated within the usual time, four 
required from two and a half to seven months, one was dismissed un- 
cured after more than six months of treatment, and two died. Gurlt 
urges, very properly as it seems to me, that there are so many other 
factors involved in these cases that it is difficult to draw any positive 
conclusions concerning the influence of the treatment in causing the delay 
of the consolidation. 

Soon after the introduction of the immovable dressing in the treat- 
ment of fractures, the charge was made that it favored non-union or 
delay of union, especially if applied immediately after the accident. 
Malgaigne pointed out that the cause in the cases cited was not the 
early application of the dressing but possibly its too tight application, 
and the correctness of this explanation has been amply demonstrated 
clinically and experimentally. Malgaigne was at a loss to reconcile 
some of the facts with the theory of too great compression and sought 
an additional cause in the prolonged withdrawal of the limb from the 
light and air, a circumstance to which attention had first been called by 
Cloquet as the cause of the changes occasionally observed in those times 
and known as local scurvy. The picture drawn by Cloquet, 2 and quoted 
by Malgaigne as too exact to be improved, of this condition of the limb 
corresponds to nothing that has come under my observation or that is 
described by modern writers, and I am disposed to believe, therefore, 
that while the prolonged retention of fixed dressings may favor its pro- 
duction, yet the actual cause is to be sought elsewhere, probably in the 
wretched hygienic surroundings of the hospital patients of those times, 

1 Gazette Medicale de Paris, 1838, p. 36. 

2 He says : " The limb seems to lose its temperature ; the skin takes on a dull white 
or leaden color, swells, and softens. The epidermis is raised and detached ; sometimes 
blebs are formed with puriform or slightly viscid contents ; the skin below them 
seems mucous and swollen ; the hair falls. If the fracture is complicated by a wound 
the granulations swell, become flabby and livid, furnish only an ichorous pus, and 
bleed at the least touch. Soon ecchymoses appear, usually about the bulbs of the 
remaining hairs, increase in size, and spread over the entire limb. The work of re- 
pair is arrested, mobility persists at the fracture at a period when consolidation should 
be complete. Sometimes hemorrhages take place at different points upon the softened 
skin. In many cases the general condition of the patient seems entirely foreign to 
these local changes ; the gums are firm, do not bleed, and are not swollen. The ap- 
petite, digestion, sleep, and moral are unchanged." 



206 PSEUDARTHROSIS AND DELAYED UNION. 

and in the moral and physical degradation of the class from which those 
patients were drawn. 1 

Mobility of the fragments, due either to the indocility of the patient, 
the inefficiency of the retentive apparatus, or the absence of treatment, 
is a common and universally admitted cause of failure or delay of union. 
Amesbury attributed to it an insufficient reduction of all but six of the 
fifty-six cases that came under his observation ; Norris says that of the 
forty-four cases in his own table in which the probable cause of the 
pseudarthrosis is mentioned twenty-two may be fairly attributed to undue 
mobility, but he adds that the information furnished in the records of 
the cases cannot be entirely depended upon. Gurlt gives the details of 
a case in which the repair of three successive fractures, thigh, leg, and 
arm, was long delayed by recurring epileptic attacks, and of another in 
which paralysis agitans produced the same result after fracture of the 
humerus. 

The premature use of a broken limb may not only result in secondary 
fracture, as has been mentioned in the preceding chapter, but may also 
arrest consolidation or even provoke absorption of the callus and result 

1 Of these surroundings and this degradation it cannot he easy to form an adequate 
conception. During one of the "glorious" periods of the history of France, say 
from 100 to 200 years ago, the descriptions of the conditions of the people furnished 
hy eye-witnesses are almost incredible. The superior of a convent at Blois, in the 
richest part of the most fertile province, says "the poor are without bread, without 
clothes, without linen, without furniture, in short, deprived of everything ; they are 
black as Moors, most of them skeletons and the children all swollen. Women and 
children are found dead in the roads and in the fields, their mouths filled with grass." 
A correspondent of Colbert writes to him " the inhabitants of this province have lived 
through the winter on bread made of acorns and roots, and now they eat the grass of 
the fields and the bark of the trees." A few years later La Bruyere writes " we see 
certain wild animals, male and female, scattered through the country, black, livid, 
burnt by the sun, attached to the soil which they cultivate with an invincible deter- 
mination ; they have a sort of articulate voice, and when they rise upon their feet 
they show a human face, and, in fact, they are men. They retire at night into dens 
where they live upon black bread, water, and roots." In 1698 a tax gatherer reports 
that in the district of Rouen which had always been one of the most industrious and 
well-to-do provinces " out of 700,000 inhabitants there are not 50,000 who eat their 
bread at their ease and sleep upon anything but straw." Similar accounts were re- 
ceived from all quarters, ''the peasants about Moulins are black, livid, and almost 
hideous ; they live on chestnuts and radishes like the beasts." Vauban writes " the 
tenth part of the people are reduced to actual beggary ; of the other nine-tenths five 
can give no alms because they are themselves almost reduced to the same need ; of 
the remaining four, three are very badly off." Massillon says, "our people are 
living in frightful misery, without beds or furniture, the only food of most of them 
during half the year is barley or oatmeal." These reports, and others like them, 
cover not a single short period, but the entire century, and the condition lasted up to 
the Revolution. From such people and from the corresponding class in the cities came 
the hospital patients. 

And how were they cared for in the hospitals ? The Hotel Dieu in Paris contained 
in 1709 more than 9000 patients, packed together four, five, nine, and even twelve in 
a single bed. r ihe beds were ranged over each other like berths in a ship, and the 
dead, dying, and living were all mingled together. The convalescent ward could be 
reached only through the smallpox ward ; the ward for surgical cases adjoined that 
occupied by the lunatics, " whose frenzied cries could be heard day and night." Not 
until 1790, less than one hundred years ago, were these conditions changed, and the 
change consisted in the removal from the hospital of a tallow chandlery and a slaughter 
house which with grim kinship had hitherto formed part of it, and in the reduc- 
tion of the number of patients to 1800, and subsequently to 800. What value can be 
placed upon statistics of results obtained upon such patients and under such con- 
ditions ? 



PSEUDARTHROSIS AND DELAYED UNION. 207 

in pseudarthrosis. This is most liable to occur in very oblique fractures 
and in those marked by much over- riding. It is not very uncommon to 
see a fractured limb bend under the weight of the body and present a 
notable deformity if the patient has been too eager to use it and prove 
his complete recovery. Callender 1 asserts very positively that move- 
ments communicated to a limb during the repair of fracture with a view 
to prevent anchylosis of neighboring joints are a frequent cause of non- 
union, especially movements of the elbow after fracture of the humerus, 
and he advises that all attempts to overcome stiffness in any joint should 
be postponed until the bone is firmly united. 

Softening and absorption of a callus that has already formed and 
become firm have been observed in a number of cases, even after re- 
covery has appeared complete and the patient has used the limb for 
some time, but more commonly at a period less remote from the accident. 
The causes usually lie in some of those diseases or complications which 
have been spoken of as occasionally delaying repair, such as erysipelas, 
phlegmonous inflammation, variola, continued fevers, scurvy, and in 
some few cases it has occurred without recognizable cause. Fanon 2 
reports a case in which the callus softened twice after fracture of the 
leg. Eighty days after the injury the limb appeared solid and the 
patient began to use it. Two days afterwards the mobility was as great 
as ever. The patient was sent to the country, and in six weeks the limb 
was again solid. After using it for a few days again the mobility re- 
turned, and then, it having been discovered that the patient had been 
rachitic in youth, she was treated with the acid posphate of lime. Seven 
months after the accident the fracture was permanently united. I re- 
produce from Malgaigne and Gurlt the following cases illustrative of the 
other causes. 

A man, forty-five years old, received a fracture of the leg which was 
consolidated by the fiftieth day. A month later erysipelas appeared on 
the leg, lasting two days; the callus disappeared and was not repro- 
duced until two months afterwards. 

In a case observed by Schelling a fracture of the femur had united so 
well that the patient could bear a certain weight upon the limb. He 
developed typhoid fever, and on the tenth day the callus had disap- 
peared. After his death, six days later, the ends of the fragments 
were found bleeding as after a recent fracture and enveloped in a sort of 
membranous sac, which contained a small amount of black liquid blood. 

A sailor broke his clavicle and was so far cured at the end of a month 
as to be able to use his arm as well as before the accident. Three 
months later, while he was hanging by the arm, the clavicle separated, 
and at the same time the symptoms of scurvy appeared. Consolidation 
did not again take place until after the cure of the scurvy at the end of 
six months. Under the same influence Marrigues saw the callus of a 
fracture that had been healed six months soften and disappear. A 
second consolidation followed the cure of the scurvy. 

Holscher cured a pseudarthrosis of the radius by resection. A year 

1 Med. Chir. Trans., vol. 51, p. 161. 

2 L'Union Medicale, 1859, vol. ii. p. 24. 



208 PSEUDARTHROSIS AND DELAYED UNION. 

and a half afterwards the patient became greatly reduced by diarrhoea 
and hectic fever, and the bones, which had been soundly united, again 
separated. 

Guersant treated a fracture of the femur in a boy ten years old ; by 
the twentieth "day firm union was obtained without shortening. The 
child was taken shortly afterwards with smallpox, the callus became pain- 
ful, and he died on the seventh day. The autopsy showed overriding to 
the extent of 1 J inches ; the callus was a soft ecchymotic mass, and the 
fragments were united by strings of a fibrous appearance. At no point 
in the callus was there the least sign of calcification. 

Kirkbride saw a man, twenty-one years old, who, a month after he 
had been discharged from the hospital cured of a compound fracture of 
the leg, returned with an ulcer over the seat of the fracture ; about 
three weeks later the ulcer became gangrenous, and before this was over- 
come the callus had been absorbed. By the application of caustic pot- 
ash to the ulcer and the bare ends of the bones the former was healed, 
and the latter reunited in six weeks. 

Finally, there is the case mentioned at the beginning of this chapter, 
in which a second fall caused a second fracture before the first was 
entirely healed, and led to the absorption, not only of the callus, but 
also of the entire shaft of the humerus. 

Gurlt maintains, in opposition to Malgaigne and Amesbury, that there 
exist a few cases in which non-union has resulted without recognizable 
cause in strong and healthy patients, and notwithstanding favorable con- 
ditions and appropriate treatment of the fracture. He cites in support 
of this opinion those cases of multiple fractures in the same patient, or 
the same limb, of which some unite and others remain ununited, and 
those of fracture of the forearm, in which only one bone unites. 

The diagnosis of non-union is made by the persistence of mobility 
beyond the period usually sufficient for consolidation, but the recognition 
of the exact condition of the parts is often difficult. This is to be ob- 
tained by palpation of the part, by recognition of the surrounding soft 
callus if one exists, or of the atrophied and separated ends of the bones, 
of the degree of mobility, by examination with acupuncture needles to 
determine the direction of the fracture and the relations of the fragments 
to each other, and by study of the subjective symptoms, the pain which 
accompanies even slight movements in delayed union, and the freedom 
from pain, even with extended movements, in true, well-established pseu- 
darthrosis. Crepitation, which exists only in the latter case, is not com- 
mon, and has the characteristics of that w T hich is found in joints altered 
by disease rather than of that found after recent fracture. 

The distinction between non-union and simple delay, so important in 
determining the method of treatment, cannot always be made by the 
objective symptoms ; the freedom of motion, the amount of pain, and 
the length of time that has elapsed must be taken into account. This 
distinction has an important therapeutic influence, because delayed 
union can usually be corrected by measures that do not involve any 
risk to the patient's life, such as fixation of the limb, reduction of dis- 
placement, change of surroundings, better nourishment, and stimulation 
of the fracture ; while, on the other hand, true pseudarthrosis requires 



PSEUDARTHROSIS AND DELAYED UNION. 209 

operative interference. While no definite period can be named after 
which pseudarthrosis alone can be said to exist, yet it may be stated, as 
a general rule, that the longer the time that has elapsed since the injury 
was received, the greater is the probability that a cure can be effected 
only by operation. 

The following case quoted by Gurlt from Casper's Wochenschrift, 
1846, p. 39, shows, -however, that a cure is possible without operation, 
even after a very long period ; an oblique fracture of the leg in a man 
more than forty years old, which had remained ununited for a year 
and a half, consolidated perfectly during a rest in bed for six weeks, 
rendered necessary by an intercurrent disease. 

Many cases are recorded in which the existence of a false joint did 
not interfere materially with the usefulness of a limb, the patients in 
some cases wore braces or supports, which gave the necessary stability 
even when the fracture was of the leg; or thigh, but in others the use- 
lessness of the limb ivas so complete, and the motions communicated to 
it by the ordinary movements of the body so painful, that amputation 
has been urgently desired and occasionally performed. During the pre- 
sent century many operative measures have been introduced for the relief 
of this disability, and all have had a certain degree of success, so that 
amputation on account of pseudarthrosis is now rarely required. The 
most unfavorable cases for a cure by operation are those in which the 
ends of the bone are markedly atrophied. 

Treatment. — Although the risks of active operative interference have 
been much reduced of late years, yet the rule of practice laid down 
many years ago in these cases still holds good ; the milder measures 
must be first employed, and an operation should be undertaken only after 
these have proved unsuccessful. Simple delayed union that has existed 
for only a few weeks without any marked displacement of the fragments 
or other recognizable local cause can usually be cured by the use of the 
immovable dressing persevered in for three or four weeks ; and in all, 
except perhaps the older cases, this measure should be tried and perse- 
vered in for many months, if partial gradual improvement can be recog- 
nized. With this must be combined the removal of any local or gen- 
eral cause, such as the overriding of the fragments, the existence of a 
constitutional dyscrasia, insufficient nourishment, and prolonged confine- 
ment to bed. The patient should be encouraged to get into the sunlight 
and the open air. Remedies taken internally have not fairly established 
a claim to confidence. The phosphates and magnesia have been fre- 
quently administered, and mercury, pushed to salivation, has been 
credited w T ith several successes in non-syphilitic cases. Its systematic 
use is of course indicated in patients presenting the specific taint. 

As a means of stimulating the nutrition of the limb, and thus promot- 
ing the growth and consolidation of the callus, I should try the descend- 
ing constant current, the influence of which in this direction has been 
amply demonstrated. 1 I have met with only one instance of its use in 
pseudarthrosis, Broca's case referred to in Bognaud's thesis (see p. 
203)', and in this it seems to have been used only for the purpose of 

1 Onimus & Legros, Traite d'Electricite Medioale, 1872. 
14 



210 



PSEUDARTHROSIS AND DELAYED UNION 



restoring their functions to the disabled nerves. Gurlt refers to three 
cases in which electricity was used, but does not state whether it was the 
interrupted or the constant current. Apparently it was used as a local 
irritant. 

Local measures have been employed in great variety, but with only 
two special objects : first, that of producing a more or less severe local 
irritation at the fracture or in its neighborhood, with the hope of thereby 
stimulating the reparative process ; and, second, restoring the parts by 
an operation to the condition of a recent but compound fracture. 

The first method finds its simplest form in the application of irritants 
to the surface of the limb over the fracture ; the tincture of iodine, 
blisters, and issues have been used, and successes have been claimed for 
each, but it seems probable that the cure was due mainly, if not entirely, 
to the immobility in which the limb was kept during the treatment. 

Irritation of the seat of fracture, of the callus, or of the ends of the 
bones is produced in a great variety of ways, some mechanical, others 
operative. Direct pressure with a tourniquet or graduated compresses 
has been used, especially in cases where the fragments have not been 
properly immobilized, and a large but soft callus has formed; in angular 
displacement it is used to restore at the same time the proper direction 
by pressure upon the projecting angle. Slight but frequently repeated 
irritation in non-union of the lower extremity is obtained by making 
the patient walk while the limb is protected from mobility or angular 
displacement by a snugly fitting apparatus. This may be one of the 
immovable dressings, or, better, an apparatus of leather and iron made 
to fit very accurately. Such a one, devised by 
Prof. H. H. Smith, of Philadelphia, is represented 
in figs. 118 and 119, and has yielded several 
cures. The objection to it is that the amount of the 
irritation, being under the control of the patient 
rather than of the surgeon, may be excessive, and, 
especially if accompanied by some mobility, may 

Fig. 119. 





H. H. Smith's splint foi 
ununited fracture of the 
thigh. 



H. H. Smith's splint for ununited fracture of the leg. 



lead to more or less absorption of the callus, and 
thus be harmful rather than beneficial. 

Violent friction of the ends by seizing the frag- 
ments, one in each hand, and rubbing them against 
each other not only sets up a certain degree of 
irritation, but also ruptures fibrous bands, and 
may tear off similar coverings from the ends of 



PSEUDARTHROSIS AND DELAYED UNION. 211 

the bone and thus restore it partially to the condition of a recent frac- 
ture. The plan is an ancient one, and has furnished many cures. It 
needs to be repeated on several successive days until the seat of the 
fracture becomes tender and swollen, and then the limb must be care- 
fully immobilized. 

Complete rupture of the fibrous bands uniting the fragments is, ac- 
cording to Gurlt, one of the best and least dangerous measures that can 
be employed. It is most suitable in those cases in which the bone is 
united by dense fibrous tissue, especially if there is overriding. An- 
aesthesia is required. The patient is so placed that the lower fragment 
projects entirely beyond the edge of the bed or table, and then it is 
pressed forcibly downwards until the tissues are felt to crack and the 
lower part of the limb is brought to a right angle with the upper. 'It is 
then bent to the same distance in the opposite direction, and moved freely 
about until the surgeon is assured of its complete mobility, after which 
it is treated as a recent fracture. Such force as can be exerted by the 
hands of the surgeon is usually sufficient, but instruments may be re- 
quired, especially to obtain the necessary extension. Gurlt says that 
the procedure, violent as it seems, is not followed by much reaction, and 
that suppuration is not to be feared. On the contrary, the reaction is 
sometimes insufficient to result in the formation of a callus. He prefers 
it to the milder method of simple permanent extension, which has been 
much employed in ununited fractures of the thigh with overriding. 

Subcutaneous scarification of the ends with division of the fibrous bands 
has been used with the same object, but apparently with much less 
success, and has now been practically abandoned ; and long fine needles 
have been thrust between the fragments and left in place for some time 
in order to provoke the desired reaction. This latter plan is sometimes 
very difficult of execution on account of the irregularities in the line of 
fracture. Malgaigne, 1 apparently, was the first to try it, in 1847, but 
although he made thirty-six attempts to pass the needle, all failed, and 
in the ten years that elapsed before the publication of his book he does 
not seem to have tried it again. He reports a success by Wiesel. 

Irritation by galvanic currents has been used in connection with acu- 
puncture ; Agnew's tables contain five cases of fracture of the leg thus 
treated successfully. 

The seton, passed between or beside the fragments, appears to have 
been employed once or twice toward the end of the last century, but its 
introduction as a method of treatment is undoubtedly due to Physick, of 
Philadelphia, who, in 1802, cured by this means an ununited fracture 
of the humerus. He first made extension to bring the fragments 
into place and then passed a silk ribbon between them and left it 
in place until consolidation seemed nearly complete five months after its 
introduction. Subsequent operators left the seton in for a much shorter 
period, and some, including Physick himself, found it occasionally neces- 
sary to aid its passage by a preliminary incision down to the bone. 
Norris's table gives 46 cases with 36 recoveries and 2 deaths thus dis- 
tributed : — 

1 Loc. cit., vol. i. p. 307. 



212 PSEUDARTHROSIS AND DELAYED UNION. 

Bone. Cases. Cures. Deaths. 

Femur .13 9 1 

Leg . ; 10 10 

Humerus ...... 16 10 1 

Forearm . 6 6 

Jaw ■ . 1 1 

Malgaigne adds to this list other cases not included in it, but mentioned 
in the paper, and also, apparently, the 15 instances in the table in which 
it is mentioned in the column of " methods which had previously failed," 



and constructs the following table theref 


rom : 


— 






Bone. Ca^-es. 


Cures. 


Failures. 


Deaths. 


Humerus 


30 


13 


16 


1 


Femur 


18 


9 


8 


1 


Leo; or tibia ..... 


14 


13 


1 




Either or both bones of the forearm 


6 


6 






Clavicle 


2 


2 






Jaw ....... 


1 


1 






Acromion ..... 


1 









72 44 25 3 

Agnew's table contains 73 cases ; 28 were cured and 8 relieved ; 34 
were failures, 2 died, and of 1 the result was not known. The two 
deaths appear to be those of Norris's table. Gurlt's analysis of his own 
table contains 143 instances of the use of the seton, including only the 
arm, forearm, thigh, and leg, with 68 cures, 10 improved, 59 failures, 3 
deaths, and 3 unknown results. The 3 deaths were after operations upon 
the thigh (2) and arm (1), in 32 cases of the former and 68 of the latter. 
Agnew's table, although certainly prepared as late as 1875, contains 
only 10 cases reported since 1859, and only 3 of these since 1864 
(1865-68), a fact which may be taken as an indication that the method 
is falling into disuse. I have not seen or heard of a case in the last ten 
years. Norris speaks of it as " one of the safest, least painful, and 
most effectual of the numerous operations that are performed for the 
cure of pseudarthrosis," but adds that the separation or direction of the 
fragments, or the abundant deposit of callus may prove an insurmount- 
able obstacle to its use. In noticing this statement Gurlt points out very 
properly not only that these obstacles exist in a considerable proportion 
of cases, but also that the records of the operation do not entirely bear 
out Norris's estimate of its safety and efficiency, and that the largest 
proportion of failures is found after its use upon the humerus. An ex- 
amination of the recorded cases shows that the dangers are increased, 
while its efficiency is not, by the prolonged retention of the seton ; there- 
fore, if used, it should be withdrawn as soon as a sufficient degree of 
irritation, for the recognition of which, unfortunately, no rule can be 
laid down, has been set up, probably, in about a week. 

Perforation of the ends of the bone was first employed by Dieffenbach 
in 1841, but after trial in two cases, one of which was cured and the 
other improved, was abandoned by him for the insertion of ivory pegs. 
It was then suggested to Detmold 1 by a reverse process of reasoning 

1 Oral Communication. 



PSEUDOARTHROSIS AND DELAYED UNION. 213 

after the publication of Dieffenbach's successes with the ivory pegs, and 
successfully used by him September 4th, 1850, 1 and again, he tells me, 
shortly afterwards in the presence of a committee of the New York 
Academy of Medicine. The method, however, is commonly associated 
with the name of the late Prof. Brainard, of Chicago, who forced it upon 
the attention of the profession in various articles. 2 The theory of the 
method is that the perforation of each fragment at one or more points 
near the line of fracture is sufficient to excite the desired productive 
osteitis without danger of suppuration. Brainard used a triangular 
pointed drill made of very hard steel, and placed the limb during the 
operation in a short metal splint perforated at various points. The drill 
was passed through one of these perforations and prevented from pene- 
trating too deeply by a sliding clamp which could be fixed by a thumb- 
screw at any desired point on its shaft. He recommended that after the 
drill had been forced well into or through the bone it should be partly 
withdrawn and made to penetrate again at another point or in a different 
direction. 

Agnew's table contains 51 cases thus treated: 32 were cured, 2 im- 
proved, and in 17 the operation failed. 



Bone. 


Cases. 


Cures. 


Improved. 


Failu 


Humerus . 


. 14 


6 


1 


7 


Radius and ulna 


7 


4 




3 


Femur 


. 8 


5 




3 


Tibia and fibula 


. 19 


14 


1 


4 


Patella 


. 1 


1 






Inferior maxilla 


2 


2 







So far as I am able to judge, the operation is regarded favorably by 
American surgeons, and is among the first of the operative methods em- 
ployed in any given case. It is unsuited to cases in which there is much 
irreducible longitudinal displacement. In the cases in which I have 
seen it used but little force has been required to perforate the bone. In 
a case reported by Dr. Weir, 3 in which a drill with a flattened point was 
used, the point of the instrument broke and remained in the bone ; the 
patient died of erysipelas, apparently originating in an abrasion of the 
skin. 

In 1846 Dieffenbach treated successfully an ununited fracture of the 
humerus by inserting an ivory peg into each fragment half an inch from 
its end, and leaving them in place for two weeks. The plan was based 
upon the knowledge obtained by experiments upon animals that the pres- 
ence of a foreign body in bone provokes an abundant formation in its 
neighborhood. The operation is done by passing a narrow-bladed knife 
directly down to the bone and following it with a gimlet or drill, which 
is then made to perforate the bone completely. A cylindrical peg of 

1 This case is reported in the New York Med. Gazette, 1850, p. 232. The fracture 
was of the tibia, and two holes were bored transversely, and one obliquely upwards, 
the latter beginniug 1^ inches below the fracture and penetrating the upper fragment 
for an inch or more, rfandford is also referred to by Brainard assh-aving perforated 
the bone before 1850, but his operation (Trans. Am. Med. 'Association, 1850, p. 355) 
was simply division of the fibrous bone with a tenotome. 

2 The principal one is in the Transactions of the Am. Med. Association, 1854, p. 
557. Thirteen cases were reported by him in the Chicago Med. Journal, Sept. 1858. 

3 New York Med. Record, March 8, 1879, p. 235. 



214 PSEUDARTHROSIS AND DELAYED UNION. 

ivory, slightly smaller than the gimlet, is oiled and driven into the open- 
ing until it projects about half an inch on the opposite side. The other 
fragment is treated in the same manner, a dressing of oakum or lint 
placed over the incisions, and the pegs, the ends of which are left pro- 
jecting above the surface, withdrawn after deep pain begins to be felt in 
the bone. If the tissue between the fragments is lax it must be lacerated 
by incision, or by free movements. 

The operation exposes to the chance of excessive suppuration and 
other accidents of compound fracture. Gurlt's 21 cases of the opera- 
tion and its modifications show no deaths and 14 cures ; Agnew's 58 
similar cases give 1 death and 36 cures. 

The modifications consist mainly in the substitution of metal for the 
ivory pegs, and in sometimes using the peg to fasten the fragments 
together by driving it through both. Occasionally the pegs have been 
cut off level with the bone and the wound left to close over them. Under 
these circumstances the ivory pegs become eroded, and may disappear 
entirely by absorption or become encysted. 

Trendelenburg exhibited at the Tenth Congress of the German Gesell- 
schaft fur Chirurgie 1 a specimen of pseudarthrosis of the lower end of 
the femur which had been cured by the introduction of an ivory peg 
through the knee-joint. At the death of the patient, two and a half 
years afterwards, the peg was found unchanged, except by the separa- 
tion of the end which had been left projecting into the joint, and which 
w T as found imbedded in the capsule. At the same meeting Riedinger 
exhibited preparations to show the superiority of bone pegs to those 
made of ivory. The bone pegs apparently became structurally united 
with the bone into which they were introduced. 

Caustic potash has been applied with success to the ends of the bones 
after division or removal of the intermediate fibrous tissue ; the applica- 
tion is continued until a black slough forms, and is repeated if necessary. 
The actual cautery has been used in the same manner. 

Resection of the end of one or both fragments was first performed for 
the relief of pseudarthrosis in 1760 at the suggestion of White of Man- 
chester, and is said by Gurlt to have been, with the exception of the 
seton, the method most frequently resorted to. It owed this favor doubt- 
less to its radical character, to the promise it held out of speedy union 
by restoration of the parts to the condition of a recent fracture and 
their accurate coaptation ; but its dangers, which were those of com- 
pound fracture, proved so great that many surgeons hesitated to employ 
it, and Sir Benjamin Brodie condemned it entirely. The great reduc- 
tion of these dangers by the use of antiseptic dressings has again brought 
it into favor, and the journals now contain comparatively frequent re- 
ports of its use. The operation consists in the division or excision of 
the intermediate fibrous band, and the freshening of one or both frag- 
ments by the saw or chisel, and sometimes in the fastening of them 
together by a wire suture or ligature, or by transfixion with pins of 
ivory or metal. 

A longitudinal incision is made over the fracture on the side that per- 

1 Supplement to Centralblatt fur Chirurgie, 1881, No. 20, p. 21. 



PSEUDARTHROSIS AND DELAYED UNION. 215 

raits the easiest access to the bone with avoidance of the main vessels 
and nerves, and is carried down to the bone by drawing the muscles 
aside, or by cutting through them if necessary. The uniting band is 
divided or stripped oif, each end turned out, and its surface freshened 
with the saw or bone-pliers, the fresh surfaces- being so shaped as to 
favor their subsequent coaptation to the greatest possible extent. If the 
bone is covered by thick masses of muscle, or if the fracture is near a 
joint it is not always easy or even possible to turn out the ends, and then 
the freshening must be done with a chain-saw, metacarpal saw, or chisel. 
The periosteum should be preserved to favor the formation of an exter- 
nal callus, but it does not seem desirable to carry this to the extent 
practised in one or two cases of stripping up a sleeve of periosteum from 
each end and sawing off the corresponding parts of the bone, so that one 
sleeve can be engaged within the other. 

Only as much bone should be taken away as is necessary to thoroughly 
freshen the ends and make the desired coaptation possible ; but the loss 
of substance involved in this removal is less important in the upper than 
in the lower extremity. 

If the surgeon desires to fasten the bones together he may surround 
them with a loop of wire, if the line of contact is sufficiently oblique, or 
perforate them with a drill and pass a wire through the holes thus made. 
The fragments are brought close together and fixed by twisting the wire, 
or by passing a canula down over its ends to the bone and fixing them 
by twisting on the outside. Or the ends of the wire may be cut short, 
if antiseptic dressings are used, and left to become encysted. If the line 
of fracture is oblique, a metal peg or screw may be driven through one 
fragment into the other. The wire or pin should be left in place for a 
length of time that varies with the size of the bone and the consequent 
rapidity of repair, but, as a general rule, it may be removed in the course 
of two or three weeks. The wire is removed by untwisting it and draw- 
ing it out, a procedure which is sometimes difficult. MacOormac has 
sought to obviate this difficulty by passing a stout pin through the bones 
and placing the wire in the form of a figure-of-eight over its two ends ; 
by the withdrawal of the pin the wire is freed. 

Yolkmann 1 treated a pseudarthrosis of the tibia with much overriding 
by notching each end for two inches and fastening them together by 
means of two ivory pegs, as shown in fig. 120. A gypsum splint was 
applied and the wound treated antiseptically ; it healed promptly down 
to a small fistula, and the pegs which had then become loose and eroded 
were withdrawn in the seventh week. No mobility could be detected 
at that time, and the patient was dismissed cured four weeks afterwards, 

In one case Roux sought to immobilize the fragments by sharpening 
one and forcing it into the medullary canal of the other, and apparently 
with success ; but unfortunately the patient had a fall two months after- 
wards and broke the arm again, after which amputation became necessary. 
Hamilton says he has done the same, but does not state the result Holt- 
house 2 tried it unsuccessfully. 

1 Berlin. Klinischer Wochenschrift, 1875, p. 221. 

2 Lancet, 1864, i. p. 326. 



216 



PSEUDARTHROSIS AND DELAYED UNION. 



The indications which determine the choice of a method of treatment 
have been pointed out in connection with the different methods, and they 
vary so greatly with the pathological conditions of the fracture that it is 
hardly possible to summarize them profitably except in the most general 



Fig. 120. 




Volkmann's operation for pseudarthrosis. 

terms. As a rule, the milder methods are to be preferred in all cases in 
which there is reason to consider the case as simply one of delayed 
union, and these measures must of course be directed to removing the 
cause of the delay, whether it be a general or constitutional vice or a 
local obstacle, such as mobility or displacement. In addition, local irri- 
tation by friction or by perforation with a drill may properly be used. 
Resection, I believe, may be stripped of most of its danger by strict an- 
tiseptic precautions, and in cases of real pseudarthrosis and disease of 
the fragments it is the only method that holds out much prospect of 
success. 

Palliative measures consist in the application to the limb of an appa- 
ratus that will supply the necessary solidity. Such an apparatus must 
ordinarily consist of a snugly fitting leather case, possibly strengthened 
by longitudinal strips of metal. 

Amputation may be required to save the patient's life after the failure 
of an operation to cure the pseudarthrosis and the occurrence of profuse 
suppuration or gangrene ; or it may be demanded by the patient as a 
relief from a painful and burdensome limb, especially if the non-union is 
associated with necrosis or caries and interminable suppuration. 



DEFORMED, FAULTY, OR VICIOUS UNION. 



21 



CHAPTER X. 



DEFORMED, FAULTY, OR VICIOUS UNION. 



Fig. 121. 



Besides the temporary and permanent causes already mentioned 
which may interfere with the functions of a limb that has been broken, 
there are others yet to be considered which depend upon the irregular 
union and position of non-articular portions of the bone, upon the ex- 
cessive size of the callus, or upon the inclusion in the latter of muscles 
or tendons. 

The inclusion of a muscle or tendon in a callus is not a common com- 
plication, and most of the recorded instances have been in the forearm 
or leg. The following case is a note- 
worthy example: Chassaignac 1 pre- 
sented a specimen of fracture of the 
radius and ulna with complete fusion 
of the bones. The pronator quadratus 
was atrophied, and pronation and supi- 
nation abolished. The extensors of 
the index finder were transformed into 
a fibrous band attached to the callus. 
One of the extensors and one of the 
flexors of the little finger were fixed 
in like manner and interrupted at the 
callus. 

It is possible that in the earlier 
stages of the less severe cases of this 
character the muscles or tendons might 
be successfully and safely freed by an 
operation under the antiseptic method, 
but if the tissue has itself become ossi- 
fied nothing can be hoped for from any 
treatment. 

Mention has been made in Chapter 
VII. of the inclusion of a nerve within 
a callus, and of the possible pressure 
of an exuberant callus upon the nerves 
that pass over it. It seems probable 
that the latter is not a sufficient cause 
of the pain that is experienced in such 
cases, but must be aided by previous 

. . ' J f \icious union after fracture of the femur. 

injury to the nerve resulting in a neu- (Gurit.) 




1 Bull, de la Soc. Anatomique, 1842-43, p. 339. 



218 DEFORMED, FAULTY, OR VICIOUS UNION. 

ritis which is kept up perhaps by the pressure. Usually when an over- 
grown callus produces disability, it does so by establishing firm union 
with an adjacent bone, or by opposing a fixed mechanical obstacle to the 
motions of a joint. Common examples of the former are furnished by 
fractures of the' forearm, and an extreme one of the latter is represented 
in figure 121. It is taken from a specimen of fracture of the shaft of 
the femur united with much shortening. Movements at the hip-joint 
were entirely prevented by a bridge of bone uniting the pelvis with the 
seat of fracture. 

The most frequent kind of vicious union, and the one commonly re- 
ferred to when this term is used, is that in which the fragments are 
united with a degree of displacement that interferes seriously with the 
form and functions of the limb. It is convenient for the present purpose 
to divide this pathological group into two principal varieties, differing in 
their anatomical characteristics and in the nature of the resulting disa- 
bility, according as the fracture involves the shaft or the articular end 
of a bone. Of these, only the former will be here considered ; its examples 
present a certain degree of uniformity in their elements and treatment, 
while the latter can be better considered in detail and in connection with 
the different fractures. 

Vicious union of the shaft of a long bone is union with angular, longi- 
tudinal, lateral, or rotatory displacement to an extent which causes a 
notable deformity or diminution of function. It is most important, most 
likely to require surgical treatment, after fracture of the leg or thigh, 
because changes in the length or shape of the lower extremity are more 
commonly productive of functional disabilities than similar changes in 
the arm, and more amenable to treatment than those of the forearm. 

This disability may be due not only to shortening or rotation of the 
limb, but also to change in the direction of the long axis of the lower 
segment which makes it necessary to evert the foot in order to bring the 
sole fiat upon the ground, and thus the internal lateral ligament of the 
ankle is exposed to an excessive and constant strain. Or the weight of 
the body may cause pain at the seat of fracture by increasing the ab- 
normal angle existing there, or the point of a fragment may irritate the 
soft parts and cause persistent ulceration. 

The causes are the same as those Avhich produce displacements, for 
the condition is simply the persistence of a displacement produced at the 
time of the accident, and left unreduced, or occurring in the course of 
the treatment as the result of defective contention, of too early use of 
the limb, or of insubordination on the part of the patient. 

Of 149 cases collected by Gurlt of vicious union requiring an opera- 
tion for its correction 71 were of the thigh, 59 of the leg, 12 of the arm, 
and 7 of the forearm. Of the fractures of the thigh which resulted in 
it the position was indicated in 56 ; in 20 of these it was in the upper 
third, in 10 above the middle, and in 21 at the middle. The character 
of the displacement was indicated in 55 ; in 38 of these it was angular 
with the convexity directed outwards or outwards and backwards, and in 
9 outwards and forwards. Of 37 fractures of the leg in which the loca- 
tion of the fracture is mentioned, 18 were in the lower third and 8 below 
the middle; of 8o in which the direction of the apex of the angle formed 



DEFORMED, FAULTY, OR VICIOUS UNION. 



219 



by the displacement is given, it was forwards in 18, outwards in 8, and 
inwards in 7. 

In 3 cases in which badly united fracture of the fibula led to operative 
interference, the symptoms were : a depression above the external malleo- 
lus, marked prominence of the internal malleolus, increase of the distance 
between the two, and extreme eversion of the sole of the foot ; and in 
one case the astragalus had slipped up between the bones of the leg. 
When this displacement is associated with bony ankylosis of the ankle- 
joint (figures 122 and 123) it cannot be corrected, and the only treat- 
ment is resection or amputation. 



Fi<?. 122. 



123. 





Vicious union after fracture of the fibula. 



Vicious union after fracture of the fibula 2% 
inches above the tip of the malleolus. 



The methods of treatment present four varieties: 1st, the straighten- 
ing of the limb by immediate infraction or bending of the callus, or 
gradually by a moderate force constantly applied ; 2d, forcible rupture 
of the callus ; bd, division of the callus ; 4th, resection of projecting 
portions of the bone. 

1. Infraction or Bending of the Callus. — Bending of the callus at a 
single sitting is possible only before complete ossification has taken 
place, but gradual bending and straightening by a moderate force acting 
constantly can be accomplished even after three or four months. This 
method is only the later application of that inspection and correction 
which was recommended by the older surgeons to be made when neces- 



220 DEFORMED, FAULTY, OR VICIOUS UNION. 

sary in the course of any case, and has been practised from the earliest 
days. The operative procedure in the rapid form consists of extension, 
counter-extension, and coaptation, the latter being made by pressure 
upon the prominent angle by the hands alone, or with the aid of the 
knee. If the angular displacement is associated with overriding exten- 
sion is necessary both to reduce the displacement and to maintain the 
reduction when obtained. The operation is simply the reduction of a 
displacement while the callus is still incomplete, and after this is. done 
the usual precautions are still to be taken to secure immobility in a good 
position. 

Gradual bending is accomplished either by extension and counter- 
extension in the usual manner, or by constant lateral pressure upon the 
projecting angle. Two principal methods of exerting the latter are in 
use : a splint is applied on the open side of the angle and the limb is 
bound to it by a circular roller or bands tightened several times each 
day, or by elastic bands ; or the splint is applied upon the convex side 
and the distal segment of the limb drawn towards it by the same means. 
Careful padding is needed at all points of pressure. This method is apt 
to be painful, and is inferior in most cases to the rapid method done, if 
necessary, with the aid of anaesthesia. 

The change in the direction of the bone is accompanied by the break- 
ing of some portions of the callus, and the difference, therefore, between 
this and the second method, in which the callus is completely broken, is 
one of degree rather than of kind, and the surgeon in attempting either 
may find his object accomplished by the other. 

u l. Rupture of the Callus. — This method, which appears to have been 
used in very early times, is mentioned, according to Malgaigne, by the 
earlier writers only to be condemned because it was feared the bones 
would break at other than the points desired. Toward the end of the 
17th century, Purman 1 used a machine for the purpose, but his example 
seems to have had no followers until in 1782 or 1783 Bosch found an 
old iron apparatus which appeared to have been made for this purpose. 
He had another constructed in a modified form and used it successfully 
upon two cases in 1783, one of them being a fracture of the femur in 
the twenty-eighth week, the other a fracture of the leg. He repeated 
the operation a number of times, and once, in 1811, in the presence of 
Oesterlen, who repeated it in 1817 and published the case together with 
several of Bosch's. 

Bosch's original instrument was like a book-binder's press ; he modi- 
fied it a number of times and many instruments have since been devised 
by different surgeons. They are known as osteoclasts, and the force is 
usually exerted by means of a screw. One of the simplest, Rizzoli's, 
consists of a stout steel bar supporting a pad in the centre and a ring at 
each end, all movable upon it. The limb is passed through the rings 
which are then fixed at the selected points, and the intermediate pad is 
screwed down upon the bone at the point where the fracture is to be 
made. A very powerful instrument capable of accurate adjustment has 

1 Grosser nnd ganz nen gewundener Lorbeer-Krantz, oder Wund-Artzney, 1692. 
Quoted by Grurlt. 



DEFORMED, FAULTY, OR VICIOUS UNION. 221 

been made by Collin & Co., of Paris, for the purpose of making supra- 
condyloid fracture of the femur for the relief of genu valgum, and could 
probably be used with advantage also' in cases of vicious union. 1 Prof. 
Sauds 2 speaks highly of the accuracy and certiiaty wish which it pro- 
duces its results. 

The injuries inflicted in the rupture of a callus are less than those ac- 
companying an ordinary fracture, because the force required to effect it 
is less and is applied in such a manner that it does not cause displace- 
ment and laceration of the soft parts. It has already been shown that 
when fragments are united with much displacement, which is the condi- 
tion in vicious union, the callus is usually comparatively scanty and 
remains friable for a considerable time, and experience has shown that 
secondary fractures produced intentionally or by accident heal, as a rule, 
more promptly and with less reaction than primary fractures. Of the 
numerous cases collected by Gurlt there was but one in which suppura- 
tion occurred, and in that the ultimate result was good, and only one in 
which subsequent union failed. Malgaigne, on the other hand, refers to 
three cases in which death followed the operation. In the first, per- 
formed by Ali Rodoham, the patient, a man 70 years old, appears to 
have died upon the table ; in the second, reported by Morgagni, the 
patient died of the remoter complications of the fracture ; and in the third, 
reported by Laugier, death took place an hour and a half after the ope- 
ration. 

Gurlt gives a table, made up of cases collected by him, in which the 
callus was ruptured, with or without the aid of instruments, after the 
lapse of the period of time which is usually sufficient for complete con- 
solidation, that is, ten weeks for fractures of the thigh and eight weeks 
for those of the leg. It is arranged in two groups according to the age 
of the patients, those under fifteen years composing one, all older ones 
the other. The cases show, as he points out, that forcible rupture is a 
successful and safe method of treatment, even after the lapse of a period 
of time that has often been considered an absolute contraindication. In 
10 of the adult cases more than six months had elapsed, the longest 
period being twenty-one months, and the same length of time in 8 of the 
younger cases, in 3 of them two years, and in 2 one year. The average 
age of the adult cases was thirty-three years, that of the young cases 
about seven years, the oldest being sixty-four, the youngest one and a 
half; 27 cases were of the thigh, 22 of the leg, and 6 of the humerus. 

The various kinds of medical treatment which have been suggested or 
employed, with a view to softening the callus and making its rupture 
easier, have no effect beyond causing the loss of valuable time, and the 
perforation of the callus at several points with a drill for the same pur- 
pose seems not to be of sufficient value to compensate for the additional 
risk. Gurlt's table contains 4 cases in which this latter was done ; two 
were successful, in one the fracture could not be produced, and in the 
remaining one suppuration ensued and caused death. If the drill is used 
the wounds should be allowed to heal before the callus is broken. 

1 For an instance of its successful use to relieve faulty union at the ankle, see Bull, 
de la Societe de Chirurgie, 1880, p. 419, or chapter xxvii. of this book. 

2 Proceedings of N. Y. Surgical Soc, May 10, 1881, in the Medical Record. 1881. 



222 DEFORMED, FAULTY, OR VICIOUS UNION. 

The operation consists either in extension and counter-extension by 
the hands of the operator and his assistants, or by specially contrived 
instruments, or in lateral pressure with the hands and knee, or with the 
limb resting on a table so that the weight of the surgeon's body can be 
used as the rupturing force, or in the use of the osteoclast. Usually 
lateral force is exerted upon or near the apex of the angle, that Is, in 
the direction in which it tends to diminish the displacement, but Dieften- 
bach has recommended that it should be exerted at first in the opposite 
direction, increasing the angle, as is often done in cases of ankylosis. 
As soon as the surgeon is made aware by the sound or the mobility that 
the callus has been broken he reduces the displacement as gently as pos- 
sible by traction or lateral pressure, and when this reduction is complete, 
or has been carried as far as is considered prudent, he applies the 
dressings. 

I find no mention made by the authors of rupture of the main arteries 
or nerves during this operation, and yet it seems a not impossible acci- 
dent when the deformity has lasted a long time and these organs lie on 
the side of the concavity. 

In this connection may be mentioned also an operation proposed and 
performed by Rizzoli in 1347, that of fracturing the corresponding bone 
of the other limb and seeking its union with a shortening equal to that 
of the first. The idea appears to have been suggested to Rizzoli, two 
or three years before, by a case of fracture of the right femur of a man 
whose left femur had been broken twenty years before and had united 
with two inches of shortening. The new fracture was left without sup- 
port until its shortening equalled that of the other, and then it was 
placed in a fixed apparatus and allowed to unite in that position. The 
patient was afterwards able to walk without limping. 

A similar case had been treated in the same manner at Brussels in 
1840, and a shortening of three inches thus compensated for. 

I am not aware that Rizzoli's operation has ever been repeated, and it 
does not seem probable that many surgeons would be willing to recom- 
mend this means of correcting an inequality in length which could be 
sufficiently well met by a cork sole. 1 

8. Division of the Callus. — This method differs from the preceding 
one, in that it substitutes a compound fracture for a simple one. It con- 
sists essentially in an incision through the soft parts down to the bone 
and the division of the latter by a saw, chisel, or bone-pliers. Accord- 
ing to Malgaigne it was first performed by Paulus iEgineta, and is re- 
ferred to by Hildanus as having been performed by a surgeon of his 
time. Malgaigne mentions nine additional cases, two of simple division, 
and seven of resection, and Gurlt gives in his table thirty-eight cases, 
about half of which antedate the publication of Malgaigne's book. 

So far as the essence of the operation is concerned, it is immaterial 
whether the bone is simply divided or a wedge-shaped piece removed ; 
the additional danger in the latter case is due to the greater laceration 

1 A well-known New York surgeon, however, about fifteen years ago excised four 
inches of the shaft of a sound femur in order to make the length of the limb the same 
as that of the opposite one, which had been shortened by excision of the hip-joint. 
This case also remains unique. 



DEFORMED, FAULTY, OR VICIOUS UNION. 223 

of -the soft parts. This is a detail which depends upon the character of 
the displacement and the form of the callus. Langenbeck modified the 
procedure by using a very narrow saw for the division of the bone. He 
first made an incision about half an inch long, through which he intro- 
duced a drill and perforated the bone ; he then passed the saw into the 
hole, and cutting first in one direction and then in the other, divided 
the bone almost entirely. After the wound thus made had filled with 
granulations, he fractured the bone at the weakened point and reduced 
the displacement. 

Within the last four or five years many osteotomies have been per- 
formed upon the curved bones of rachitic children, and upon the femur 
in cases of genu valgum under antiseptic precautions with an almost 
entire absence of dangerous accidents or complications. The method of 
procedure is to make a short longitudinal incision down to the bone, in- 
sert a chisel, turn it transversely, and divide the bone by repeated blows 
with a heavy mallet, the limb resting meanwhile upon a sand-bag. The 
wound is then syringed out with a 2 j- per cent, solution of carbolic acid, 
dressed with carbolized gauze, and the limb placed in a splint. Usually 
the dressing does not need to be changed, and the wound heals by pri- 
mary union. If the cellular tissue projects through the incision in the 
skin it should be cut away below the level of the latter so as not to inter- 
fere with its union. It is recommended also, that the sides of the wound 
should be kept in apposition by a narrow strip of adhesive plaster crossing 
its centre. The uncovered portion of the wound provides for the escape 
of any discharge. 

I have not met with any case in which this method has been applied 
to a badly united fracture, although Malgaigne 1 proposed it as less dan- 
gerous than division with a saw, but I feel sure it would be equally 
serviceable in cases of angular or rotatory displacement without such 
overriding as would greatly increase the thickness of the bone at the 
point where the fracture would have to be made. 

In long- standing cases in which the disability is due more to the de- 
fleeted position of the foot than to the shortening, as in some badly 
united fractures of the leg, and when the principal indication, therefore, 
is merely to correct the faulty direction of the lower segment, and in 
similar cases of extreme angular displacement of the thigh in which there 
is reason to suppose that the tissues on the concave side have become 
permanently shortened, it is better to resect a V-shaped piece, or even 
a piece of considerable length, than simply to divide the bone, so that 
the limb may be made straight without undue or dangerous tension of 
the soft parts. 

In view of the great diminution of dangers by the use of the antiseptic 
methods, the tabulation of the results obtained under the other methods 
of treatment does not seem necessary, or even useful. It is sufficient to 
say that the 38 cases collected by G-urlt give 25 cures, 1 improvement, 
1 failure, 2 amputations, and 7 deaths, and in 2 the result is unknown. 

4. Resection of a Projecting Fragment. — In some cases the defect of 
the union is found not in shortening or change of the direction of the 

1 Loc. cit., vol. i. p. 339. 



224 



DEFORMED, FAULTY, OR VICIOUS UNION". 




Fig. 124. limb, but simply in the projection of the end of one of 

the fragments which by its pressure may irritate and 
cause ulceration of the skin, and be the source of much 
discomfort, or even disability. The same condition may, 
but much more rarely, be the consequence of an over- 
growth of the callus. It occurs most frequently after 
oblique fracture of the humerus or tibia (fig. 124). 

The indication is plain, and the treatment simple and 
free from danger. A -longitudinal incision is made 
over the projecting bone, and the latter freely exposed 
and then removed with the saw, bone-pliers, or chisel. 
The sides of the incision are then brought together and 
primary union sought except at the point where the 
drainage tube is left. 

In making a choice among these means of correcting 
vicious union the surgeon must be guided by two facts : 
1st, that a simple fracture is a lesion which does not 
practically involve any danger to the patient's life, 
while a compound fracture, notwithstanding the vastly 
improved results obtained under antiseptic treatment, 
must be considered as a much graver injury ; and 2d, 
that the less the length of the time that has elapsed since 
the receipt of the original injury the greater is the pro- 
bability of success by the milder methods. The first 
will lead him to employ the milder methods whenever 
there is any hope of succeeding by their aid ; the second 
will guide him in the choice between immediate or gradual straightening 
and forcible rupture, or, when taken in connection with the extent and 
character of the displacement, may force him to resort to the more 
dangerous division of the callus. 

In all cases in which not more than two months have elapsed, the first 
method holds out a good prospect of success, and it should be resorted 
to at once without losing any time in vain measures intended to soften 
the callus. In fractures with much displacement this period may be 
considerably lengthened, for these are the fractures in which repair 
takes place most slowly, and the callus remains soft or friable longest. 

When a choice can be made forcible rupture is to be preferred to 
division by the saw. One objection which has been urged against it, 
that of an alleged difficulty of producing the fracture at the desired 
point, has been shown to be unfounded. The instruments at our dis- 
posal enable the fracture to be made with great precision. Another 
objection, that of subsequent failure of the bones to unite, has been urged 
against refracture. There is, so far as I know, but one recorded instance 
of such failure, and the objection, if it be a valid one, is equally good 
against division. 

If division is chosen it must be performed with the strictest attention 
to the details of the antiseptic method ; and resection of a portion of the 
callus or of the bone must be made whenever there is reason to suppose 
that the tissues in the concavity of the limb are permanently shortened. 



Vicious union 
after fracture of 
the tibia. 



DEFORMED, FAULTY, OR VICIOUS UNION. 225 

Subcutaneous division of the tendo Achillis may take the place of this 
resection in some faulty unions of the leg with an anterior angle. 

I have no means of determining the extent to which surgical interfer- 
ence is justifiable in cases in which a callus has united the bones of the 
forearm and destroyed the function of rotation of the wrist. 

The resection of a projecting fragment or portion of callus is an easy 
and safe means of removing what may be the cause of serious discom- 
fort or disability, and the surgeon should not hesitate to do it when a 
plain indication arises. 



if) 



226 GENERAL PROGNOSIS 



CHAPTER XI. 

GENERAL PROGNOSIS. 

The prognosis after fracture involves consideration of the effects of 
the injury with respect to the prolongation of life, the preservation of 
the limb, its usefulness if preserved, and the period of time required for 
convalescence. The different factors in this prognosis have been con- 
sidered, many of them in detail, in the preceding chapters, and I shall 
therefore only group them here for a more convenient general view. It 
has been said recently by a prominent German surgeon that a fracture is 
now to be considered rather as an inconvenience than as a misfortune, 
but while the remark may contain an element of truth, it is far too sweep- 
ing. We have seen that the life of the patient may be endangered not 
only by a compound fracture of a limb but also by a simple one, and 
that in almost any case the functions of the part are liable to be crippled 
for a considerable period of time, and perhaps permanently. 

The prognosis varies with the age and condition of the patient, the 
character, position, and origin of the fracture, and the complications to 
which it may give rise. 

1st. The Patient.— Sex does not affect the prognosis. Age has a great 
influence upon it ; the younger the patient the better the prognosis. In 
children the bones unite more promptly, and usually with less permanent 
deformity, and compound fractures are less serious. But in fractures 
involving or in close proximity to joints the prognosis, qua function, is 
affected unfavorably by the strong tendency that exists during youth and 
childhood to excessive formation of callus when the displacement is not 
entirely corrected. On the other hand, if the injury is such as to call 
for excision of the joint the probability of a reproduction of bone suffi- 
cient to create a new and serviceable joint is good. In old people the 
prognosis is worse because in the more severe cases they are less able to 
recover from the injury, escape the complications, and bear the necessary 
confinement to the bed. The latter is an especially grave element in the 
prognosis which is further aggravated by the pain. Furthermore, their 
joints are more likely to become stiffened, and their tissues to remain 
engorged and rigid. They are also especially liable to certain fractures, 
such as those of the wrist and neck of the femur, which entail necessarily 
a greater or less degree of deformity or disability. 

The general condition of the patient seems to be without any very 
serious importance so far as the repair of the fracture is concerned ; 
even in those rare cases in which there is a congenital or acquired pre- 
disposition to fracture, the bones, as we have seen, unite within the 
usual period. On the other hand, the existence of a special dyscrasia 
such as syphilis or scurvy, or an acute intercurrent disease may delay 



GENERAL PROGNOSIS. 227 

or entirely prevent repair. Paralysis of the affected limb may or may 
not affect the process, according to conditions which have been elsewhere 
detailed. 

2d. The Fracture. — Fractures by direct violence are, as a rule, more 
severe than those by indirect violence, because in addition to those lesions 
which are common to both forms there is also in the former the bruising 
of the soft parts produced by the external force, and the consequent in- 
creased probability of suppuration. And when the violence is great, as 
in the passage of a car-wheel across a limb, the bone is usually com- 
minuted, the muscles torn, and the vessels and nerves bruised and lace- 
rated. In gunshot fractures the prognosis is especially bad as regards 
the preservation of life or limb, the duration of the treatment, and the 
functional consequences. They are frequently associated with injury to 
important vessels or nerves, the tissues traversed by the ball are so 
bruised that suppuration is practically inevitable, and as bones deeply 
placed are as liable to be thus broken as the superficial ones the chances 
of efficient drainage are less. In addition, the injury to the bone itself 
is more severe, for it is shattered, splintered, and usually fissured. 

Although improved methods of treatment have reduced the mortality 
after compound fracture the prognosis still remains much more serious 
than after simple fracture. Repair takes place more slowly, the patient 
is exposed to more numerous and more serious complications during its 
progress, and the functional disability is usually greater and more pro- 
longed. When such a fracture involved a large joint, as the knee, 
amputation was formerly considered almost inevitable ; we have now 
learned that the limb can often be preserved, sometimes even with a 
useful joint, sometimes only after excision, but the risk is always a great 
one and secondary amputation may be required. 

Fractures of some bones carry with them special risks because of 
their relations to important viscera, as fractures of the skull, the spinal 
column, the hyoid bone or larynx, the ribs, and the pelvis. 

Fractures of the short or spongy bones unite more promptly and usually 
with less deformity than those of the shafts of the long bones, and the 
same is true of the spongy ends of the latter except when the fracture 
enters the joint. Small bones heal more quickly than large ones, and 
the bones of the face more quickly perhaps than any others. The shafts 
of the long bones are attached to so many muscles, the tendency to con- 
traction of the latter is so constant, and the counteracting effect of the 
different groups upon each other is so completely annulled by the frac- 
ture of the lever that the probability of union with more or less dis- 
placement and shortening is very great. This result may give occasion 
to so much dissatisfaction on the part of the patient that it is important 
it should be known to be unavoidable under many circumstances. Its 
cause, as we have seen, may lie in conditions that are entirely beyond 
the control of the surgeon, and he must not be held responsible for the 
limitations of our art. The surgical section of the American Medical 
Association 1 meeting at Chicago in 1877 gave expression to this fact in 
formal resolutions adopted after discussion of the subject. They said: 

1 Transactions, vol. xxviii. p. 507. 



228 GENERAL PROGNOSIS. 

"It is the opinion of this Section that shortening in cases of fracture of 
long bones is the rule in practice, regardless of any of the plans of 
treatment now in use." 

A controversy ,. regrettable on account of the personal issues which it 
has raised, has been since carried on between two of our prominent sur- 
geons upon this point, and has brought out very plainly the fact that 
even if the resolutions may be considered too sweeping by some they 
express what is undeniably true in many cases, the impossibility of 
insuring union without shortening. The assertion that a good, even per- 
fect, result after fracture of the femur can be insured by making com- 
plete reduction under ether, and then so fixing the limb in an immovable 
plaster apparatus as to maintain the reduction until union has taken 
place will be accepted by all as the correct statement of a principle, but 
of one which unfortunately cannot always be embodied in practice. The 
action of the muscles is not the only cause of displacement, and even 
when it is the cause permanent extension will not always overcome it ; 
and, secondly, the plaster dressing does not furnish complete permanent 
extension, because of the absence of an upper fixed point of support. 

In superficial bones the displacement is more easily recognized, and 
for this as well as for other reasons the prognosis is somewhat better 
than after fracture of bones that are covered by thick layers of muscles. 
When the corresponding bones of both limbs are broken the surgeon 
loses the standard of length and form furnished in other cases by the 
uninjured limb ; but, except perhaps in the case of the femur, this loss 
is not serious. The fracture of one of two parallel bones has a better 
prognosis than that of both, because the remaining bone acts as a splint 
and subsequent union of the two bones by the callus is less probable, a 
union which entails great functional disability in the case of the forearm, 
but is without serious consequences in the leg or ribs. Fracture of a 
bone at two or more points is very likely to be followed by permanent 
shortening, because of the difficulty of restoring the intermediate frag- 
ment to its proper position. 

In articular fractures the prognosis must be guarded, for in addition 
to the functional losses that may be caused, there is also danger of sup- 
puration of the joint, of caries or necrosis, or of the production of a 
chronic synovitis, especially in the young and strumous. If the fracture 
is not comminuted and if the displacements can be reduced, recovery with 
almost complete preservation of function may be obtained, but such a re- 
sult is rare. In many cases, as in fracture of the neck of the femur or of 
the humerus, the displacement can be neither recognized nor corrected, 
and in others, at the same points, bony union is practically impossible, 
and although such patients may be able to use the limb with some comfort 
and freedom, the great majority are permanently and seriously crippled. 
Fractures of the patella and coronoid process of the ulna may be ex- 
pected to heal by fibrous union, and the degree of disability depends 
partly upon the length of the fibrous band. 

In fractures combined with dislocation of the same bone, the prognosis, 
with reference to function, depends largely upon the possibility of re- 
ducing the dislocation. When the fracture is situated upon the shaft at 
some distance from the joint the reduction of the dislocation under ether 



GENERAL PROGNOSIS. 229 

will usually present much more than the usual difficulty, and when the 
fracture is near the joint and the dislocated fragment is a small one it 
may be impossible to act upon it at the time, and the reduction must be 
made, if at all, after the fracture has united. , 

The less extensive the fracture, the better the prognosis. Infractions 
heal most quickly and with least tendency to displacement ; transverse 
fractures more quickly than oblique ones, because of the greater tendency 
of the latter to shortening and transverse displacement, Splintered 
fractures and fractures with long fissures involving the medullary canal 
are especially liable, if compound, to suppuration and to dangerous 
osteo-myelitis, and the former are exposed, as has been shown in Chap- 
ter VII., to the late formation of an abscess after apparent recovery. 

For the prognosis in the different complications which may arise in 
the course of the treatment the reader is referred to the sections speci- 
ally devoted to them. 



230 FRACTURES OF THE SKULL. 



CHAPTER XII. 

FRACTURES OF THE SKULL. 

This class of injuries, one of the most obscure and important in sur- 
gery, owes its special interest not to the lesion of the bone, but to those 
of the , brain or its coverings which are so frequently associated with it 
and lead so often to a fatal result. From the earliest times injuries of 
the head have been attentively studied with regard both to the mechan- 
ical questions involved in the production of fractures and to the treat- 
ment to be pursued. The coexistence of a wound of the soft parts has 
always been looked upon as a formidable complication, one which added 
to the dangers arising from pressure upon the brain those due to the 
contact of the air with the exposed parts, and therefore, as active interfer- 
ence could not be made in any case of simple fracture without creating 
this communication, the strong tendency of all surgeons in the last half 
century, I may say the positive teaching of all, was to temporize until 
the appearance of symptoms of intra-cranial inflammation should force 
the surgeon to attempt the removal of the actual or supposed cause. 1 In 
some cases the reaction was slight or entirely absent and the patients 
got well under this expectant plan ; in others the tardily undertaken 
operation failed to arrest the progress of the dangerous symptoms or 
seemed even to make it more rapid, and thus surgeons were confirmed 
in the policy of non-interference, not only in cases where there was no 
proof of fracture but also in others with both fracture and depression of 
the bone but without external wound. 

While such views were held concerning treatment, fractures of the 
skull were not to be separated practically from the larger class of in- 
juries of the head, and had but little in common with fractures of the 
limbs. But now the practice is changing under the influence of the 
improved methods of treating wounds, and even when a fracture is not 
compound many surgeons do not now hesitate to cut down upon the 
bone and apply the trephine if depression or even a fissure is found, so 
that it seems desirable to depart from the practice of former writers and 
include this class of injuries also among fractures. 

Fractures of the skull are by no means rare ; in the table of statistics 
given in Chapter I., there are 757 cases of this kind in a total of 51,398 
fractures. They occur in patients of all ages and both sexes, but are 
most frequent in adult males for reasons depending upon the greater 
exposure of that class of the community to the accidents and violences 
which are the most common causes of the lesion. These causes are 

1 Views radically opposed to this were held by some of the earlier surgeons, nota- 
bly Percy and Boyer, who advised the application of the trephine even in cases of 
simple contusion without fracture, as a means of preventing intra-cranial suppuration. 



FRACTURES OF THE SKULL. 231 

usually falls from a height or blows received from falling bodies or in 
personal encounters. 

The fractures of the vault are for the most part direct, that is, the 
bone is broken at the point where the blow is received ; fractures of the 
base may be indirect, or by transmitted violence, or may be due to the 
extension of a direct fracture of the vault. Some fractures of the base 
are caused by falls from a height upon the feet, knees, or buttocks, the 
force being transmitted to the base of the skull through the vertebral 
column, and in some exceptional cases of falls upon the head the frac- 
turing force is the momentum of the body impinging directly upon the 
base of the skull at the occipito-atloid articulation and crushing the 
bone as between a hammer and anvil. The term fracture by contre- 
coup has been much employed in the sense of " indirect fracture," the 
use originating apparently in an erroneous view of the mechanism by 
which the injury is produced. It was supposed that, the skull being 
globular in form and elastic in structure, a blow received at any given 
point of its surface might be so transmitted as to exert a fracturing force 
at the opposite or at some intermediate point. This view was supported 
by the fact that blows upon the head often cause extravasations of blood 
at distant points within it ; but it has been recently shown by Duret 1 that 
the mechanism of these extravasations is entirely different from that to 
which it was formerly attributed. He showed by well-devised experi- 
ments that when a violent blow is received upon the vault of the skull, 
with or without fracture, the sudden depression of the bone causes a 
wave of cerebro-spinal liquid to pass from the point that is struck and 
from the ventricles of the brain to the base, and this wave causes rupture 
of the meningeal and cerebral vessels by distension of the meshes of the 
pia mater and arachnoid during its passage and by the sudden diminu- 
tion of the extra-vascular pressure which follows its subsidence. By 
some surgeons the term fracture by contre-coup is applied only to cases 
in which the fracture occurs at a point diametrically opposite to that at 
which the blow is received ; by others its use is extended to those cases 
also in which the fracture is at any intermediate point ; and by others 
again, according to Duplay, to cases in which the head, being driven by 
the blow against some solid body, is fractured at the point which receives 
the second impact. This last use is clearly unjustifiable, for the fracture 
is a direct one. It is denied by some authors that cases of the first 
kind can exist, but, in view of two facts mentioned by Legouest and 
Servier, 2 I think the possibility must be admitted. These two facts 
were a fracture of the frontal bone produced by Perrin by throwing a 
skull forcibly upon its occiput, and a limited fracture of the occipital 
bone caused by a fall upon the anterior portion of the vertex. In the 
latter case the patient died in a few hours, the point that received the 
blow was recognized by the contusion, there was no fracture under it 
and no fissure connecting it with the fracture of the occipital. 

The structure and form of the skull have a marked influence upon the 

1 Etudes experimentales et cliniques sur les traumatismes cerebraux, vol. i. 
Paris, 1878. 

2 Diet. Encyclopedique des Sciences Medicales, art. Crane, p. 598. 



232 FRACTURES OF THE SKULL. 

character and extent of a fracture. In accordance with its variations in 
thickness and with the relations of some of its^parts to other bones some 
portions are more easily broken than others, and lines of fracture begin- 
ning at given points on the vault and extending to the base usually follow 
corresponding lines quite closely. The bone itself is composed of an 
outer and inner table separated by the softer and vascular diploe and 
differing in thickness and brittleness, the inner table being the thinner 
and more brittle. At the lower portion of the frontal bone are found 
the frontal sinuses, irregular cavities of variable size which appear dur- 
ing childhood and increase in size through adult life. They are situated 
between the two tables of the bone, and sometimes extend as high as to the 
frontal eminences and outwards over almost the whole of the orbit. Their 
importance in connection with fractures lies in the separation between 
the two tables by which a fracture of the outer without injury to the 
inner one is rendered easy. The thickest portions of the vault are at 
the base of the frontal bone, the mastoid region, and the occipital tuber- 
osity ; the thinnest at the squamous portion of the temporal and the in- 
ferior fossae of the occipital. Fractures of the vault are produced by 
direct violence ; fractures of the base by the extension of fissures from 
the vault, by the direct impact of the vertebral column, by force trans- 
mitted through the bones of the face, and occasionally by direct violence 
as in gunshot wounds or in blows with a pointed weapon traversing the 
orbit, nostril, or mouth. 

Pathological Anatomy. — This division into fractures of the vault, of 
the base, and of both is practically of great importance, since they dif- 
fer materially in their gravity, and the former alone offer an opportunity 
for direct surgical interference. 

Fractures of the Vault. — With few and rare exceptions, the possibil- 
ity of which has been admitted, fractures of the vault of the skull are 
produced only by direct violence, the fracture taking place at the point 
where the blow is received, and consisting either of a simple fissure or 
of comminution, and either with or without accompanying depression. 
A fissure is usually of considerable length, and may involve more than 
one bone, crossing a suture. Its sides are usually in contact, but may 
be separated by a slight interval if the fissure is long. Comminution is 
the result, usually, of a blow with a blunt instrument delivered with 
much violence, and is seldom accompanied by fissures extending to any 
considerable distance. When such a fracture is extensive the affected 
area commonly presents an irregular, funnel-shaped depression, the sides 
of which are formed by the fragments which remain in contact along the 
periphery with the undepressed portion and slope inwards to the centre 
(fig. 125), which lies at a distance below its normal level, varying from 
a few lines to an inch or more ; or the fragments may be driven bodily 
inwards and entirely separated at the borders from the solid portion, or 
the depressed portion may consist of two principal pieces sloping inwards 
to a central line of greatest depression (fig. 126), one of them, perhaps, 
overriding the other. The inner table is always more extensively frac- 
tured than the outer, except when the fracture is produced from within 
outwards, as by a bullet, in which case the outer table is the one most 
injured (fig. 127). This peculiarity has been attributed to the greater 



FRACTURES OF THE SKULL, 



283 



brittleness of the inner table, but it is due to mechanical causes, and is 
similar to what is seen after fracture of other substances. The dura 
mater is usually torn, but rarely to an extent at all comparable with that 
of the aggregated lines of fracture. 



Fii?. 126. 



Fig. 125. 



Fig. 127. 

iiiifi 





Compound depressed fractures of the skull. 




Fracture of the skull from within 



In exceptional cases the bone, or at least its outer table, is raised above 
its normal level instead of being depressed. Mr. Hewett 1 says two such 
specimens are preserved in the museum of St. George's Hospital ; in 
each a fragment involving the entire thickness of the bone is bent out- 
ward or raised up like the lid of a box, remaining attached to the skull 
along the border which forms the angle. The injury was caused in one 
case by a falling chisel, and in the other by a fall upon an iron railing, 
one of the spikes of which penetrated the skull. A similar case came 
under my observation at Bellevue Hospital ; the patient was struck upon 
the back of the head with a chisel, one corner of which traversed the 
bone, splintering the inner table, and turning up the outer table along 
the edge of the incision. The mechanism is readily understood: after 
the instrument has penetrated the bone its direction is slightly changed, 
and it acts as a lever, prying out the bone on one side instead of forcing 
it in on the other. 

Permanent traumatic depression of the bone without fracture in the 
adult is unknown and inconceivable. It has been shown by experiment 
that the elasticity of the skull is such that a point upon its surface can 
be depressed one-third of an inch Avithout fracture, but the elasticity 
which permits this prevents the depression from persisting after the re- 
moval of the force which produced it. It is possible, perhaps, in the 
softer and more pliable bones of the infant, but even there it is doubtless 
associated with partial rupture of the tissue. 

The term incomplete is applied to fractures involving only one of the 
tables. They are of rare occurrence, but unquestionable examples of 
each variety have been recorded, and cases of extensive splintering of 
the inner table, with only slight injury of the outer table, are not un- 
common. Fracture of the outer table alone may easily occur at the 



1 Holmes's System of Surg., Am. ed., vol. i. p. 618. 



234 FRACTURES OF THE SKULL. 

frontal sinuses, but is rarely met with elsewhere, although it is possible 
wherever the diploe is thick and soft. I observed a case at the Presby- 
terian Hospital in 1881 ; the patient, a man twenty-one years old, had 
fallen from a considerable height, striking upon his head. The bone, 
which was freely exposed through two large scalp wounds at the vertex, 
presented two long fissures, one parallel to and half an inch to the left 
of the sagittal suture, the other posterior to and nearly at right angles 
to the former, along the middle of the left parietal bone. I applied the 
trephine at the centre of each fissure, removing only the outer table in 
the second one, and enlarging the opening with bone-pliers along the fis- 
sure until it measured about an inch in length ; the exposed inner table 
was carefully examined and showed no trace of a fissure. The patient 
made a rapid recovery. 

Fractures of the inner table alone are rare, but have been demon- 
strated both by operation and by autopsical examination. The greater 
brittleness of the inner table seems to be entirely foreign to this limita- 
tion of the injury, the cause of which lies solely in the direction of the 
fracturing force. Legouest and Servier refer to a specimen preserved 
in the museum of Guy's Hospital, which shows a fracture of the exter- 
nal table alone caused by a force acting from within the skull, and is, 
in their judgment, a conclusive proof of the correctness of this opinion. 
Additional arguments in its favor and in opposition to the other view, which 
was formerly held very generally, are furnished, as was first shown by 
Mr. Teevan, by the study of the mechanism of fracture of any homo- 
geneous tissue, and by observation of the manner in which a thin plate 
of ice yields under a slowly acting fracturing force. 

Mr. Hewett says that if a fracture of the vault is accompanied by a 
wound of the integument the fracture is much more frequently limited 
strictly to the seat of the blow than in cases of simple fracture. In 
twenty cases of compound fracture this limitation existed eight times, 
while in fifty-six cases of simple fracture it existed only once. 

Fractures of the Base. — The base of the skull differs from the vault by 
the irregularity of its form, the lack of homogeneousness in its structure, 
the great variations in its thickness, and the presence of many foramina. 
Yiewed from within, it presents on each side three fossae at different 
levels, the highest in front, the anterior, middle, and posterior. Of these, 
the middle one is formed mainly by the temporal bone, and is the one 
most frequently fractured, apparently because of its position in the line 
in which blows are most frequently received. The inferior borders of 
the parietal bones are bevelled on the outer side and fit within the tem- 
porals, so that a downward force exerted upon the parietals at or near 
the sagittal suture and tending to spread them outwards is counteracted 
by the temporals which act as buttresses or as chords to the arc. In 
addition to this strain the temporals are subjected also to the crushing 
one produced by the action of the blow upon the vertex and the resist- 
ance offered by the vertebral column, between which two points they are 
interposed. 

In general terms it may be said the provision against fracture of the 
base by indirect violence is made by thick ridges radiating from the 
occipital condyles, while the intermediate portions, being thus relieved 



FRACTURES OF THE SKULL. 



235 



from the necessity of supporting the strain, are left comparatively thin 
and weak. This arrangement is analogous to that found in other parts 
of the skeleton, and is in accordance with the general principle observed 
throughout of combining the maximum of strength with the minimum of 
weight. While thus protecting the brain from those forms of violence 
to which it is most frequently exposed, this arrangement, however, leaves 
it comparatively unprotected against others to which it is occasionally, 
but much more rarely subjected, that is, against those which tend to 
produce direct fracture. 

Fractures of the base may be direct or indirect. Direct fractures 
are rare, and usually the result of gunshot wounds, but there are not a 
few recorded cases of fracture produced by comparatively slight direct 
pressure upon the thin portions of the base, such as the roof of the orbit, 
the horizontal plate of the ethmoid bone, or the sphenoid, exerted by such 
things as a cane, a foil, a tobacco pipe thrust into the orbit or the nostril. 

The orbit is the most frequent channel through which this injury is 
received, and the cases are remarkable for the slight degree of violence 
which was sufficient to produce the fracture and for the apparent absence 
or the unimportant character of the external wound, in one case only an 
apparently slight scratch upon the eyelid, in another a wound of the con- 
junctiva undiscovered during life, the weapon having passed between the 
lids. In a case reported by Pamard 1 the point of a foil passed between 
the eye and the inner wall of the orbit, broke the plate of the ethmoid, en- 
tered the cavity of the cranium by the inner wall of the sphenoidal fissure, 
and fractured the posterior clinoid process. In another case a testy old 
gentleman, irritated by some one behind him, made a backward thrust 
with an umbrella and drove it through the orbit of his tormentor into the 
brain ; in another, 2 a soldier fencing with a comrade with canes received 
a thrust in his left nostril. He died a few days afterwards with cerebral 
symptoms, and at the autopsy the ferrule was found lying beside the 
sella turcica, the body of the sphenoid having been perforated by the 
cane, and the posterior clinoid pro- 
cess broken off. A similar case Fig. 128. 
(fig. 128) is reported in the first 
volume, page 337, Surgical History 
of the War of the Rebellion. 

Direct fracture of the basilar pro- 
cess has been caused by the dis- 
charge of a pistol into the mouth 
with suicidal intent ; and, finally, 
may be mentioned Harlow's unique 
and very remarkable case reported 
by Bigelow 3 of a tamping-iron 3 J 
feet long, 1J inches in diameter, 
and weighing 13 \ pounds which was 
driven by the premature explosion of a blast directly through a man's 
skull, entering the cheek by the angle of the lower jaw, and passing 




Fracture of the clinoid process by a sword- 
thrust. (U. S. Surg. Hist j 



3 Gazette HeMomadaire, 1865, p. 455. 

2 Dublin Medical Journal, 1851, vol. i. p. 347. 

3 Am. Journal Med. Sciences, July, 1850. 



236 



FRACTURES OF THE SKULL. 



entirely through and out at the centre of the frontal bone near the 
sagittal suture. The patient recovered without paralysis or intellectual 
trouble, but with the loss of sight in the eye of the injured side. 

Fracture of the squamous portion of the temporal bone has also been 
produced occasionally by a blow upon the chin driving the condyle of 
the lower jaw through into the cavity of the skull, and Mr. Jordan 
Lloyd 1 reports two cases of fracture of the external auditory process 
(on both sides in one case) by violence received upon the chin. The 
diagnosis was made by bleeding from the ear and by recognition of an 
irregularity in the wall of the canal at the part corresponding to the 
condyle of the jaw. Neither the cavity of the cranium nor the temporo- 
maxillary joint appeared to have been opened. This variety is classed 
by some among the indirect fractures, but although, strictly speaking, it 
comes under the definition of that term, it is certainly identical in its 
mechanism with the direct fractures above described. 

The same remark and comment may be made concerning those very 
rare fractures limited to the neighborhood of the foramen magnum and 
produced by a fall upon the head, the momentum of the body supplying 
the force which is transmitted directly to the occipital condyles by the 
atlas (fig. 180). Dupla^ 2 quotes from Chauvel one case of death fol- 



Fiff. 129. 



Fig. 130. 




Perforation of the skull by the condyle 
of the jaw. 



Fracture of the base by a fall upon the vertex. 



lowing a fall upon the head, in which the autopsy disclosed an elliptical 
fracture surrounding the foramen magnum and circumscribing the centre 
of the base of the skull which had manifestly been driven in. The rest 
of the skull was intact. The same surgeon produced experimentally an 
analogous double fracture occupying the occipital bone alone and extend- 
ing in two lines three and five centimetres long from the posterior foramina 
lacera into the inferior occipital fossae. The cadaver was that of a man 
63 years old with complete bony fusion of the first six cervical vertebrae. 



1 British Med. Journal, 1882, vol. i. p. 190. 

2 Pathologie exteme, vol. iii. p. 467. 



FRACTURES OF THE SKULL. 



237 



Fig. 131. 




Fracture of the base by a blow on the nose. (Bryant.) 



And Sir Charles Bell 1 reports the case of a young man brought to the 
Middlesex Hospital after a fall upon the head ; he presented no important 
symptoms, and was soon discharged. As he left the hospital he fell dead, 
and the autopsy showed fracture of the borders of the occipital foramen. 
It was thought that the fragments had suddenly become displaced and 
had compressed the medulla. 

Other indirect fractures have been produced by falls or blows upon 
the face, the ethmoid being driven in by a blow upon the nose (fig. lal) 
and the orbital plate of the 
frontal by a blow upon the 
anterior portion of this bone. 
A case which is almost unique 
is mentioned by Sappey ; 2 
transverse fracture of the body 
of the sphenoid produced by a 
fall from a wagon. The pa- 
tient survived eight months, 
death being due to an arterio- 
venous aneurism originating in 
a rupture of the carotid artery 
within the cavernous sinus at 
the time of the accident. Legouest and Servier state that a somewhat 
similar fracture was produced experimentally by Perrin, and that a speci- 
men of a third is now in the Musee Dupuytren. 

Felizet 3 asserts that in fractures of the base the region of the basilar 
process has remained uninjured between the foramen magnum and the 
sphenoid. 

The great majority of fractures of the base of the skull are, however, 
produced by the extension of fractures originating in the vault, and for 
the correct appreciation of this origin we are mainly indebted to the 
labors of Dr. Aran, 4 who made a thorough experimental and clinical 
study of the subject. His experiments were made by letting cadavers 
fall from a height or by striking the skull with a large heavy hammer, 
and he summarized his results in the three following sentences : 1st. In 
no experiment was a fracture of the base produced without fracture at 
the point that received the blow ; 2d. Fractures of the vault usually 
radiate to the base, and are not arrested by the sutures ; 3d. They take 
the shortest route to the base, following the' curves of smallest radius. 

Fractures of this kind show a fissure at the point struck, usually a 
slight one, which enlarges towards the base and may extend in various 
directions, but, as a rule, follow certain definite lines determined by the 
region which receives the blow. Thus, a blow upon the front of the vault 
causes fracture of the base in the anterior fossa ; a blow upon the parieto- 
temporal region causes fracture of the middle fossa, and one upon the 
occipital bone produces lines of fracture extending towards the foramen 
magnum. Prescott Hewett 5 found these statements fully verified by ex- 



1 Surgical Observations, London, 1816. 

2 Anatomie descriptive, 2d ed., vol. i. p. 191. 

3 Recherclies sur les fractures du Crane, Paris, 1873. 

4 Archives Gen. de Meclecine, 1844, 4th ser., vol. vi. p. 

5 Holmes's System of Surgery, Am. ed., vol. i. p. (J27. 



180. 



238 



FRACTURES OF THE SKULL, 



animation of the cases of fracture of the base of the skull admitted into 
St. George's Hospital during a period of ten years. He divided the 
skull into three zones or segments. " An anterior zone formed by the 
frontal, the upper part of the ethmoid, and the fronto-sphenoid ; a middle 
zone, by the parietals, the squamous and the anterior surface of the 
petrous portion of the temporals, with the greater part of the basi-sphe- 
noid ; and a posterior zone, including the occipital, the mastoid, and the 
posterior surface of the petrous portions of the temporals, with a small 
part of the body of the sphenoid." In the less severe cases the line of 
fracture was strictly limited to one of these zones ; of 25 cases it was 
limited to the anterior zone in 5, to the middle zone in 14, and to the 
posterior zone in 6. In the more severe cases it spreads into two or 
even into all three zones ; out of 29 such cases the middle and anterior 
zones were involved in 14, the middle and posterior in 15. In 10 cases 
all three zones were implicated. This analysis shows the great fre- 
quency with which the middle fossa is involved, for of the total of 64 
cases it was broken in 53. Mr. Hewett adds that in the severer injuries 
there may be in addition small circumscribed fractures having no connec- 
tion with the main line of fracture. Thus, the roof of the orbit or the 
posterior clinoid processes may be broken independently. 

Duplay calls attention to the fact that the fracture is sometimes 
parallel, sometimes perpendicular, and sometimes oblique to the axis 

of the petrous portion of the 
temporal bone. The parallel 
fractures (fig. 132) pass in 
front, or at the level, of the 
external auditory foramen and 
end at the foramen lacerum 
anterius, dividing the petrous 
portion into two unequal parts 
of which the smaller, the ante- 
rior one, contains only a por- 
tion of the external auditory 
canal and of the middle ear. 
The perpendicular fractures 
are the most rare, and pass 
just outside of the internal 
auditory foramen, involving 
both the vestibulum and the 
labyrinth. The oblique frac- 
tures, which are much rarer 
than the parallel but more 
common than the perpendicu- 
lar ones, are situated near the 
base of the petrous portion, 
run downwards and inwards 
parallel to the tympanum, and divide the middle ear. Duplay claims 
that the parallel fractures result almost invariably from a blow upon 
the temporal region, the others from a blow upon the occiput. 

Finally may be mentioned those extensive fractures due to extreme 




A- 



Fracture parallel to the axis of the temporal bon 
(Follin and Duplay.) 



FRACTURES OF THE SKULL. 239 

violence in which all or nearly all the bones are shattered, the sutures 
separated, and the fragments displaced and movable. 

It occasionally happens in fractures both of the vault and base, that a 
venous sinus may be injured, and if the fracture is a compound one the 
injury may be followed by severe hemorrhage, which, however, is rarely 
fatal. 

The important practical pathological point in the great majority of all 
fractures of the skull is the degree and character of the associated in- 
jury to the brain and its coverings, and in this must be included not only 
the immediate lesions produced at the moment the injury is received, 
but also the more remote consequences following a permanent change in 
the inner surface of the skull by fragmentation or depression, or by over- 
growth of callus. 

Symptoms and Diagnosis. — The symptoms following an accident 
which has caused a fracture of the skull vary greatly with the part in- 
volved, and the most prominent ones are often those due to the associated 
lesions of the brain and meninges, the detailed consideration of which 
does not lie within the scope of this subject. The symptoms of the 
fractures may be best presented by following the division adopted in the 
preceding paragraphs, and grouping them as those of fractures of the 
vault and fractures of the base. 

1. Fractures of the Vault. — The positive physical signs of fracture 
are depression of the surface of the bone, which may be recognized 
through the integuments when the fracture is simple, and the existence 
of a fissure, comminution, or depression recognizable by the eye or finger 
when the fracture is compound. In the case of a simple fracture the 
diagnosis is often difficult and sometimes impossible, for not only is a 
fissure unrecognizable by the touch, but even a moderate depression may 
escape detection, especially when covered by thick muscles, as in the 
temporal region, or leave the surgeon in doubt because of the difficulty 
of distinguishing between it and an inflammatory swelling, or an extrava- 
sation of blood under the scalp which often gives to the finger the sensa- 
tion of a soft, depressible centre with a firm, hard, circular border. Or 
a congenital depression or senile thinning of the bone may be mistaken 
for the result of a recent traumatism. Duplay cites the case of a man 
who had been rendered unconscious by a fail from the third story of a 
house ; the surgeon found a broad deep depression of the skull over 
which the skin had not been bruised, and prepared to cut down upon it, 
but fortunately the patient recovered consciousness in time to escape the 
exploration by informing him that the depression was not the conse- 
quence of the fall, but had existed from childhood. Similar cases have 
been reported by others. 

When, on the other hand, the bone has been exposed, there is no 
difficulty in recognizing a fracture, or even a fissure in the wound, and 
no objection to enlarging the wound, and even scraping up the perios- 
teum if there is reason to suspect the existence of fracture in the imme- 
diate neighborhood. Error in such a case has arisen by mistaking a 
suture for a linear fracture, but it is one which should be readily avoided 
if the possibility is borne in mind, even if the suture deviates from its 
normal position or is that of a Wormian bone. 



240 FRACTURES OF THE SKULL. 

A very positive sign of fracture is the escape of brain tissue through 
the wound, or of the cerebral liquid through .the wound or under the 
unbroken skin. Mr. Hewett mentions a case in which the inspissated 
secretion of a frontal sinus was mistaken for brain substance. 

Fracture of the inner table alone may be suspected from the character 
of the violence, its existence being considered more probable when the - 
involved area is limited in extent, as in punctured wounds or blows with 
a pointed object such as a nail or spike, or from the later symptoms of 
intra-cranial suppuration, but the diagnosis can never be made positively. 
Its symptoms, physical and rational, are solely those of traumatic menin- 
gitis or cerebritis, and are, therefore, not to- be distinguished from those 
following traumatic extravasation of blood upon the surface of the brain 
without fracture. 

The presence of a fissure upon the surface is not a proof that both 
tables are broken, although it makes it extremely probable, and an inter- 
mittent flow of venous blood from it corresponding in its intermittences 
with the respiratory acts, that is, increasing during expiration, and 
diminishing or ceasing during inspiration, is not a proof that the blood 
comes either from the meningeal vessels or a venous sinus, for when it 
comes only from the diploe near a sinus it may present this character, 
as I observed in the case above mentioned of fracture of the external 
table alone. 

The rational signs are, for the reason already stated, of but little value 
in the diagnosis when the physical signs are in default. The probability 
of a fracture may be strengthened by the character of the violence which 
caused the injury, and, in exceptional cases, by a sign mentioned by 
some authors, a sound like that of a cracked pot heard at the moment 
of the accident by persons standing near the patient. Duplay says this 
sound is often heard in experimenting upon the cadaver, and always 
coincides with the production of a fracture. The presence of a localized 
pain in the head, indicated when the patient is unconscious by repeated 
movements of the hand towards the affected point, is mentioned as a 
probable sign by some writers, but certainly is not sufficient to establish 
the diagnosis. (Edema of the scalp when there is no open wound, and 
persistence of suppuration when there is one, have been long regarded 
as probable signs, but are too indefinite to be at all trustworthy. 

Haward 1 reported a symptom which is probably very exceptional, but 
which, if it occurs and is fairly recognized, is pathognomonic ; the ap- 
pearance under the scalp of a translucent, pulsating swelling due to the 
escape of the cerebro-spinal liquid. In Haward' s case the patient was 
a child 19 months old ; the tumor appeared over the right frontal bone 
after a fall upon the head, increased for ten weeks, and ruptured spon- 
taneously through the conjunctiva eight days after eight ounces of 
liquid had been removed by tapping. A large quantity of liquid escaped 
through the rupture, and it continued to flow during the three days the 
child survived. The autopsy, which was restricted to the seat of the 
fracture, showed a depression of the right frontal bone and a fracture ot 

3 Lancet, July 17, 1869, p. 79. 



FRACTURES OF THE SKULL. 211 

the arch of the orbit through which the handle of a scalpel could be 
easily passed into the brain. 

Mr. Hewett 1 gives eight additional cases of the escape of a clear 
serous liquid after compound fracture of the vault and two after tre- 
phining for epilepsy, the discharge beginning in some immediately after 
the injury, in others not until after the lapse of several days. Of the 11 
cases 8 recovered. In some of the cases the liquid came evidently from 
the lateral ventricle, either through a wound of the overlying substance 
of the brain or by distension and rupture, in others from the subarach- 
noid space. The discharge does not seem to affect the prognosis unfavor- 
ably, except so far as it may be due to associated injury to the brain. 

2. Fractures of the Base. — It is only in very rare and exceptional 
cases, some compound fractures of the more accessible portions, that 
fractures of the base present positive physical signs that can be recog- 
nized by the eye or finger. The symptoms that must ordinarily be de- 
pended upon for making the diagnosis, if we except the probabilities 
arising from the nature of the injury and the associated cerebral distur- 
bances, are the escape of the contents of the cranium, blood, cerebro- 
spinal liquid, or brain substance, through the natural openings or a 
wound, and paralysis of one or more of the cranial nerves. 

Bleeding from the mouth, nose, or ears follows certain fractures of 
the anterior and middle fossae in which a communication has been estab- 
lished between an intra-cranial bloodvessel, usually a venous sinus, and 
the cavity of one of these organs. In many fractures, however, even 
in extensive ones, such a communication is not established, and then the 
symptom is absent. 

"Bleeding from the ears in severe injuries of the head," says Mr. 
Hewett, "has for many years past been held, and deservedly too, as 
one of the most valuable diagnostic signs of fractured base. But the 
bleeding, to be of any real value as a means of diagnosis, must be of a 
serious nature, and, above all, it must continue for some time. With 
such a bleeding it may be safely diagnosed that there is a fracture of 
the base running through the petrous bone and opening up a communi- 
cation between the cavity of the tympanum and some of the numerous 
and large vascular channels which surround this bone, or with an extra- 
vasation of blood within the cranium itself." He found that out of 32 
cases of fracture of the base implicating the petrous portion of the tem- 
poral bone the bleeding from the ear was profuse and continuous in 15 ; 
in 12 of the remaining cases the line of fracture did not extend into the 
tympanum, and in 5 the tympanum was fractured but the membrana 
tympani was not ruptured. In more than half the cases, therefore, this 
sign was absent, but when present its diagnostic value was great. 
Nevertheless it is not absolutely pathognomonic, for there are quite a 
number of recorded cases in which an abundant hemorrhage from the 
ear has followed a severe injury to the head which has left the base of 
the skull unbroken. It follows occasionally fracture limited to the mas- 
toid process, and Duplay reports a case in which it was due solely to 
rupture of the membrana tympani. 

1 Loc. cit., p. 634. 
16 



242 FRACTURES OF THE SKULL. 

Hemorrhage from the mouth or nose, or vomited blood, has less diag- 
nostic importance than that from the ears. The blood comes in some 
cases from the nose or mouth after fracture of the petrous bone, making 
its way through the cavity of the tympanum and the Eustachian tube, 
and if the membrana tympani is ruptured it may escape at the same time 
through the ear. Here too the profuseness and continuance of the bleed- 
ing are a more valuable sign than the mere fact of the hemorrhage, for 
the vascularity of the mucous membrane lining these cavities is such 
that bleeding from it readily follows trifling injuries. Of the 32 cases 
of fracture of the base implicating the central bones of this region ana- 
lyzed by Mr. Hewett, bleeding from the nose or mouth, or subsequent 
vomiting of blood occurred in 14 with symptoms giving rise to the belief 
that the fracture involved some of the bones corresponding to the pharynx 
or nose ; and dissection showed that in 4 of them the fracture was con- 
fined to the ethmoid, in 3 to the body of the sphenoid, and in 1 to the 
basilar process. In 5 both the ethmoid and sphenoid were fractured, 
and 1 the basilar process also. 

Extravasations of blood under the unbroken skin, ecchymoses, have a 
similar diagnostic value for the same reasons, when they are found in 
certain locations and are not due to a local contusion of the soft parts. 
Of these the most common and most important in some respects is effu- 
sion into the orbit, due to fracture of the orbital plate of the frontal and 
of the sphenoid with rupture of the ophthalmic artery or of a venous 
sinus. The blood makes its way forward and appears first under the 
ocular conjunctiva, then under that of the lids, and finally, after the lapse 
of some time, under the cutaneous surface of one or both lids. The 
diagnostic value of the symptoms is greatest when the blow has not fallen 
upon the head near the eyes, when the blood makes its appearance at 
the different points in the order just mentioned, and when the ecchymosis 
is of considerable size. Usually the lower lid is affected earlier and to 
a greater extent than the upper one, but Mr. Hewett says he has seen 
two cases in which the ecchymosis was confined to the upper lid. 

Out of 23 cases of fracture of the base involving the orbital plates of 
the frontal bones, collected by Mr. Hewett, the nature of the injury was 
made manifest in 10 by this symptom ; in 8 cases there was no ecchy- 
mosis, either in the lids or under the conjunctiva, and in 5 the effused 
blood appeared in the eyelids alone. 

A possible source of error in making a diagnosis of fracture of the 
base upon this symptom lies in the fact that blood may, although rarely, 
be effused into the lids or under the conjunctiva after fracture of the 
malar or superior maxillary bone. 

A symptom that has its origin in a similar condition is the formation of 
so-called orbital aneurism, which is most common when the carotid artery 
is ruptured within the cavernous sinus, but may also follow rupture of 
the ophthalmic artery. In a few cases a bruit was heard within the 
head immediately, or within a very short time, after the accident, and 
the usual symptoms of protrusion of the eyeball and dilatation of the 
orbital and frontal veins followed in due time. A somewhat similar 
protrusion of the eyeball unaccompanied by a bruit and dilatation of the 
veins has been caused by an effusion of blood into the posterior portion 



FRACTURES OF THE SKULL. 243 

of the orbit. And Mr. Hewett refers to three cases in which a traumatic 
aneurism, apparently not an aneurism by anastomosis, in the back of the 
orbit was caused by fracture of the base. 

Ecchymosis in the pharynx is rarer and of less value in the diagnosis ; 
Dolbeau is mentioned by Duplay as having reported some cases, the effu- 
sion taking place into the retro-pharyngeal cellular tissue and causing 
ecchymosis and difficulty in deglutition. 

Ecchymosis of the mastoid region or of the side of the neck, appear- 
ing some time after the receipt of an injury, especially if the latter has 
taken place upon the opposite side of the head, has some diagnostic 
value, and Mr. Hewett says that sudden puffiness in the occipital region 
with ecchymosis some hours after a severe injury to this portion of the 
head may also be of use in making the diagnosis of fracture of the base. 
The blood comes from the adjoining venous sinuses, and gradually oozes 
through the fracture and makes its way to the surface. 

A watery discliar ge from the ear or nose, similar to that mentioned in 
connection with fractures of the vault, is occasionally observed after frac- 
ture of the base. It occurs more frequently from the ear than from the 
nose, and is then indicative to a certain degree of fracture of the petrous 
portion of the temporal bone. 

A watery discharge from the ear after fracture of the base is said by 
Duplay to have been vaguely indicated for the first time by BeVenger 
de Carpi, and to have been described with more detail in 1728 by Stal- 
partius Van der Weil, who had observed one case and quoted another. 
Mr. Hewett says that O'Halloran published some thirty years later 
another and even more characteristic case, but adds, that the subject, 
although known to at least one other writer, appears to have been lost 
sight of until 1839 when Laugier 1 first pointed out the connection between 
this discharge from the ear and fracture of the petrous portion of the 
temporal bone together with rupture of the membrana tympani. 

Various origins have been ascribed to this discharge, and it has now 
been proved by numerous analyses and dissections that its source is not 
always the same, and that consequently it is not so certain a sign of 
fracture of the base as has been believed and taught in the past. 

(1) Chemical analysis of the liquid in some cases showed that it con- 
tained a large amount of chloride of sodium and but little albumen, thus 
resembling the cerebro-spinal liquid ; and dissections have shown the 
presence of the lesions necessary to permit the escape of this liquid from 
the cranium, that is, fracture of the internal auditory canal extending 
into the tympanum, rupture of the membrana tympani, and laceration of 
the portion of the arachnoid which accompanies the seventh nerve into 
its foramen of exit. On the other hand, it must be admitted, all these 
three lesions have been found in cases in which this symptom was lack- 
ing. .The facts already mentioned of profuse watery discharge after 
fractures of the vault, in which the liquid unquestionably came from the 
sub- arachnoid space or lateral ventricles, lend additional support to the 
theory of this origin, if any is needed. 

(2) Fedi, quoted by Duplay, published a case in which the discharge 

' Comptes Rendus de 1'Academie des Sciences, 1839, p. 240. 



244 FRACTURES OF THE SKULL. 

from the ear lasted about thirty-four hours, and was estimated at nearly 
three ounces, but in which the autopsy showed no lesion except a frac- 
ture of the base of the stapes establishing a communication between the 
labyrinth and the cavity of the tympanum. (The membrana tympani 
must also have been ruptured or destroyed, but this is not mentioned.) 
In this case the liquid must have been the liquor Cotunnii, and its 
amount can be accounted for only on the supposition that the membrane 
lining the labyrinth continued to secrete it as it escaped. 

Mr. Hewett says there are many such cases in which dissection has 
shown that the fracture did not involve the meatus auditorius internus, 
but passed through the internal and middle ear without touching the 
meatus. 

(3) There are cases in which a profuse watery discharge from the 
ear has followed injury to the head, in which there was no fracture in- 
volving the internal or middle ear, and no communication between them. 
Hewett quotes two such cases, one dissected by Mr. Henry Gray and 
himself, and reported in the Transactions of the Pathological Society of 
London, vol. vi. p. 22, the other by Mr. Holmes ; and Duplay quotes a 
third reported by Ferri in the Gazette Hebdomadaire, vol. i. p. 59. 

In Mr. Hewett's case the patient was brought to the hospital, after a 
fall from a ladder about twenty feet high, with bleeding from the left 
ear and a scalp wound on the upper and back part of the head. The 
next day the discharge was pink and flowing at the rate of two ounces 
per hour. This flow continued for two days, then became much less, 
and on the sixth day was scanty and puriform. The patient died on the 
seventh day with diffuse cellular inflammation of the scalp, and brain 
symptoms. The autopsy showed entire absence of fracture or any in- 
jury of the temporal bone, and of communication between the internal 
and middle ear ; but the membrana tympani was ruptured and the lining 
membrane of the tympanum internally congested and covered with a 
muco-purulent secretion. 

In Mr. Holmes's case the patient was admitted with bleeding from the 
ear, which was followed by a copious watery discharge. The autopsy 
showed no fracture of the temporal bone, and no injury in the cavity of 
the tympanum or the internal ear. The lower jaw was broken just below 
the condyle, and the lower fragment had perforated the Avail of the 
external auditory canal. t 

In Ferri's case there was a watery discharge of sixty-three ounces in 
one hundred and six hours. The patient died six years afterwards of 
caries of the temporal bone of the opposite side, and at the autopsy 
there could be found no trace of fracture upon the side from which the 
discharge had taken place, but only a cicatrix of the membrana tympani 
and the signs of past inflammation of the cavity. 

It thus appears that although a profuse watery discharge from the 
ear is much more commonly associated with fracture of the temporal 
bone than with any other injury, yet it is not absolutely pathognomonic 
of that lesion, and its diagnostic value is only that of a probable symp- 
tom. This value is, moreover, affected by the circumstances of the 
appearance and character of the discharge. Thus, if the discharge 
appears promptly after the receipt of the injury, if it is distinctly watery 



FRACTURES OF THE SKULL. 245 

and is preceded by little or no bleeding, if it is abundant, one or two 
drachms in the hour, and if it is modified by change in the position of 
the head, by coughing or sneezing, the diagnosis may be considered 
positive. If, as happens in a second class of cases, an abundant and 
prolonged hemorrhage precedes the watery discharge the diagnosis of 
fracture of the base is still reasonably certain, but it is based, not on the 
watery flow, but on the bleeding, which has its probable origin in frac- 
ture of the petrous portion. There is, however, a third class of cases 
in which the preliminary bleeding is neither abundant nor prolonged, 
and the watery discharge varies in the time of its appearance and in its 
quantity, perhaps appearing soon after the accident, or being profuse for 
a short time ; in these the diagnosis is doubtful, whether based on bleed- 
ing or on the watery discharge. 

Mr. Hewett says that while it has been taught by some surgeons that 
a profuse watery discharge after an injury to the head occurs most com- 
monly in childhood and youth, the cases which have come under his own 
observation have been for the most part more than thirty years of age. 

The symptom has long been considered a very serious, even a fatal, 
one ; but that the case is not hopeless, even when the diagnosis of frac- 
ture of the base is as certain as it can be under the circumstances, is 
proved by the recoveries which have been recorded. One such recovery 
and one probable recovery have come under my own observation ; in 
both cases the discharge w T as watery, profuse, and continuous, with loss 
of hearing in the affected ear; and in each the injury was caused by a 
violent fall. One case recovered entirely, the other passed from obser- 
vation a week after the accident, but he was then doing well, and the 
discharge had ceased. Still, it is to be regretted that a chemical anal- 
ysis of the liquid has not been made in the cases that have recovered, 
in order that the accuracy of the diagnosis might be comfirmed by all 
possible means. 

A similar profuse watery discharge from the nose has been observed, 
but much more rarely than from the ear. It presented the same chemi- 
cal composition as the cerebro-spinal liquid, that is, it contained a large 
quantity of chloride of sodium, and but little or no albumen, and in one 
case, Roberts, 1 the autopsy showed a fracture (pistol-shot) of the sella 
turcica and laceration of the arachnoid and pituitary body. The liquid 
flowed freely when the body was turned upon its face ; and water poured 
upon the seat of the fracture within the skull ran out through the nose. 
It is, therefore, a reasonable assumption that the flow observed during 
life came from the large sub-arachnoid spaces underlying the brain, and 
also, perhaps, from the ventricles through the infundibulum and torn 
pituitary body. In other cases reported by Foucart and Malgaigne 
(quoted by Hewett), the temporal bone was fractured and the discharge 
reached the nose through the middle ear and the Eustachian tube. 

A possible source of error lies in the copious clear secretion which is 
sometimes poured out by the nasal mucous membrane under the influence 
of even a slight irritation. 

1 Archives Gen. de Med. 1845, 4th series, vol. ix. p. 412. 



246 FRACTURES OF THE SKULL. 

The escape of the substance of the brain through the ear or nostrils 
has been observed in a few cases of comminuted fracture, but the diag- 
nosis appears to have been plain without the aid of this symptom. 

Paralysis of one or more cranial nerves is occasionally observed in 
connection with fractures of the base, as the result either of direct injury 
to the nerve in fractures by direct violence, of rupture of the nerve or 
pressure upon it by one of the fragments when the line of fracture 
crosses its course, or of pressure by extravasated blood. The nerves 
most frequently involved are the 7th pair, the optic, and the olfactory ; 
and, according to Mr. Hewett, 1 examples are on record of injury to 
every pair except the 4th, those of the 8th and 9th being the most rare. 
He mentions a case of the latter in which the injury to the nerve was 
caused on the tenth day after the accident, by the displacement of the 
fragments. The patient was doing well, left his bed on that day, and 
walked across the ward. He was seized with rigors and vomiting, be- 
came unconscious, and died of asphyxia forty-eight hours afterwards 
with increasing dysphagia and gasping respiration. The autopsy showed 
no lesion or inflammation of the brain or its membranes ; the line of 
fracture crossed the right foramen lacerum posterius, and the bones there 
were so displaced that the right cerebellar fossa was lower than the left. 

The diagnostic value of the symptom is only accessory, because it may 
be, and frequently is, due to other lesions than fracture, such as injury 
to the brain itself, intra-cranial extravasation of blood, and hemorrhage 
within the sheath of the nerve. Paralysis of the facial nerve, however, 
has more significance than that of any other. 

The progriosis after fracture of the skull depends mainly if not en- 
tirely upon other factors than those which enter into the prognosis after 
fracture of a limb. The prognosis quoad vitam is grave because of the 
lesions of the brain or its envelopes which may be associated with the 
injury or which may arise in the progress of the case. The injury to 
the bone itself is rarely of a character to leave any disability if the 
patient survives, although a depressed fragment or an exuberant callus 
(which is rare) on the inner side may cause epilepsy or loss of mental 
power, especially if the fracture has occurred during youth. MacEwen 2 
has recently given several illustrative cases. Repair takes place as after 
fracture of the flat bones, described in Chapter VI., that is, the reparative 
material is furnished mainly by the periosteum and diploe'. The result 
of this is that the fractures are slow to unite, because the diploe is usually 
scanty, and, as compared with the marrow of the long bones or the 
spongy tissue of others, is hardly to be taken into account. It was 
shown in the Chapter on Repair how slowly the compact bone tissue pre- 
pares itself to repair a fracture, and as, for some reason which does not 
appear clearly, the pericranium and dura mater do not seem to form 
callus readily and abundantly, the labor seems to fall mainly upon the 
bone itself, and the callus is a small one. When a fragment is depressed 
and the periosteum stripped up, new bone is formed by the latter as 
under similar circumstances elsewhere. 

1 Loc. cit., pp. 655 to 659. 2 Lancet, September, 1881. 



FKACTURES OF THE SKULL. 



217 




Kepair by fibrou 



pbining. 



Loss of substance, unless very small, 
is never entirely repaired by bone, but 
the gap is filled partly by new bone and 
partly by fibrous tissue (fig. 133). 

Treatment. — Here again we have to 
distinguish between fractures of the 
vault and fractures of the base. 

Fractures of the Vault. — After Per- 
cival Pott had so improved the construc- 
tion of the trephine as to greatly di- 
minish the chance of wounding the dura 
mater which was associated with the 
use of the older instruments, it was 
held that active interference was called for in the great majority of cases, 
even when symptoms of cerebral injury or inflammation were not present. 
Pott 1 asserted that " perforation is absolutely necessary in seven cases 
out of ten of simple undepressed fracture of the skull," because it was be- 
lieved that intra-cranial inflammation would almost certainly follow even 
a simple fissure of the skull. The trepan preventif, the use of the tre- 
phine simply with the view to prevent intra-cranial inflammation, was in- 
dorsed by the Academie de Chirurgie, and all surgeons guided their 
practice by this theory until the beginning of the present century, when 
a reaction set in and extended so far that the use of the trephine became 
very rare, and w T as thought to be justifiable only after grave cerebral 
symptoms had made their appearance. Most writers upon surgery dur- 
ing the last twenty or thirty years condemn its use unequivocally except 
in compound fractures with depression and with marked and persistent 
cerebral symptoms. It would be easy to multiply citations in support 
of this assertion; the exceptions to this teaching are rare and seldom go 
beyond admitting the possible propriety of elevating depressed bone in 
compound fracture when there are no signs of compression. The influ- 
ence of this teaching is seen in the following quotation from Bryant: 2 
"At Guy's Hospital, trephining and elevation of bone have been per- 
formed in 51 cases during seven years, and of these only 12 recovered. 
At St. Bartholomew's Hospital it was recorded by Callender in 1867 
that the operation had not been performed for six years. At University 
Hospital, Erichsen gives 6 cases of recovery out of 17." I am not 
aware of the existence of any statistics that show the proportion of re- 
coveries in the cases in which the trephine was not used, and indeed this 
class of injuries does not readily allow the question of treatment to be 
decided by tables of percentages. Morgagni's warning, observationes 
perpendendos, non numerandce sunt, needs to be regarded here as much 
as anywhere, and the study of recorded cases shows, I think, that the 
mortality following the use of the trephine, and upon which its restric- 
tion is so largely based, is to be charged not to the operation, but to the 
lesions whose symptoms finally led to it after a delay that had deprived 
it of most of its chances of success. I should hesitate to express upon 



1 Injuries of the Head, p. 130. 

2 Practice of Surgery, 3d Am. ed., p. 185. 



248 FRACTURES OF THE SKULL. 

so important a point an opinion opposed to that of authors whose authority 
is confirmed by so large an experience, if it were supported only by theo- 
retical considerations, but the periodical publications of the last few years 
show that its results when carried into practice have been favorable, and 
I know that it is held and acted upon by many of the profession in New 
York, in whose knowledge and judgment I have the most confidence. 
Moreover, so far as my own observation and experience go, the practice 
of early active interference yields good results, that is, the percentage 
of success is not only very much greater than that furnished by the 
tardy use of the trephine, but is actually high, especially when the 
wound is treated antiseptically. During the last year, 1880-81, thirteen 
compound fractures of the skull have been treated at Bellevue Hospital 
by trephining, and under this term I include the use of the bone-pliers 
to remove a portion of bone so as to elevate or remove the depressed 
portions. One case was a gunshot fracture, the bullet was buried in 
the brain and the patient died in twenty-four hours. In another the 
fracture was overlooked for nearly a fortnight ; then severe brain symp- 
toms set in, the wound was enlarged, a slight depression found, and the 
trephine applied; pus was found between the dura and the bone; the 
patient died soon afterwards, and the autopsy disclosed a circumscribed 
suppurative meningitis. Of the remaining 11 two died, eight recovered, 
and one is still under treatment with hernia cerebri. Seven of these 
eleven presented no brain symptoms beyond stunning, and were operated 
upon immediately after the accident ; they all recovered, and in two of 
them the amount of bone removed was about three square inches, one of 
them being further complicated by a wound of the longitudinal sinus. 
The remaining four cases presented brain symptoms, they were operated 
upon immediately, 2 died, 1 recovered, and the fourth is the one with 
hernia cerebri, just mentioned. Within the same period I have operated 
at the Presbyterian Hospital upon two cases of compound fracture, one 
with extensive depression, the other with double linear fracture ; both 
operations were done within two hours after the accident, and both 
patients recovered without a bad symptom. In contrast to these I may 
mention two cases that have recently come under my observation, one of 
the tardy use of the trephine, the other of non-interference ; both termi- 
nated fatally, the first with suppurative meningitis, the second with ab- 
scess of the brain. Both fractures were compound and small, both 
patients walked to the hospital, and neither presented brain symptoms 
until after a week had passed. Both, I think, might have been saved 
by an early operation. 

The radical difference between the teachings of a century ago and 
those of the present time is not to be explained by any important ad- 
vance in our knowledge, either of surgical science or of the nature of 
this class of injuries. It is mainly a question of clinical experience : 
Does delay give better results than early operative interference ? And if 
surgeons during the last fifty years have practically limited their expe- 
rience to one method of treatment, they are without sufficient means to 
answer the question, for they know only one side of it, and their opin- 
ions must be judged by the aid of such knowledge as can be drawn from 



FRACTURES OF THE SKULL. 249 

the experience of others, and from the study of the nature of the lesions 
and of kindred facts. 

Curiously enough, the practice of the surgeons of the last century 
has been followed up to the present time in the mining districts of Corn- 
wall, where fractures of the skull are common, and immediate trephin- 
ing is the rule ; and the results of this practice have been recently given, 
in general terms, by Mr. Robert Hudson, 1 who bases upon them an ap- 
peal for the earlier and more frequent use of the trephine. Pie quotes 
Mr. Michell to the effect that a week rarely passed while he was a stu- 
dent without one or two operations, and that he had seen three done in 
a single day, all in the physician's office, and the patients afterwards 
walking home. Trephining is so much the rule that the miners expect 
it even in comparatively slight injuries, and it is not the use of the tre- 
phine, but the failure to use it, that requires to be explained to them. 
Mr. Hudson says the first question of the patient's friends is : " Is his 
skull broken ?" And if that is answered affirmatively, the next is : 
" When are you going to bore un ?" 

There is no lack of experience in non-traumatic cases to show that the 
operation of trephining is not in itself a dangerous one if the dura mater 
is not divided, and the experiments of Mr. Leo 2 have shown that we 
may expect the danger to be diminished, if not entirely removed, by the 
use of the antiseptic method. He trephined 26 monkeys and treated 
the wounds antiseptically ; 19 recovered, and of the 7 deaths only 1 
appeared to be due to intracranial inflammation ; 4 died in consequence 
of the extreme cold of the season, 1 from the effects of the chloroform, 
and 1 from a hemorrhage on the sixth day. All that were trephined 
and treated without antiseptic precautions died of purulent meningo- 
encephalitis. 

Chadborn trephined Philip of Nassau twenty-seven times for epilepsy ; 
and in another case the operation was performed fifty-two times upon 
one individual. Trephining for epilepsy, headache, and vertigo is com- 
mon among the barbarous or semi-civilized peoples of Africa and the 
- Pacific, who submit themselves to it coolly, often twice or three times, 
and apparently without fear of fatal results. Among the Kabyles the 
operators have a semi-religious character, and have usually undergone 
the operation themselves; the instruments are considered sacred, and are 
handed down from father to son through many generations. Between 
1850 and 1870 the operation was done quite frequently in Europe and 
the United States for the relief of epilepsy, and the later abandonment 
of the practice, except in cases having a traumatic origin, appears to 
have been the result rather of its failure to cure the disease than of the 
mortality that followed it. 

The reaction against the use of the trephine appears to have been the 
result of two causes : the success of non-interference in some cases, and 
the failure of tardy interference in others. When a case did not pre- 
sent grave brain symptoms at the outset surgeons were encouraged by 
the former to delay ; and when, finally, such symptoms had set in, and 

1 British Medical Journal, July, 1877, vol. ii. p. 75. 

2 Ibid., May 14, 1881. 



250 FRACTURES OF THE SKULL. 

the patient's chances of recovery were diminished by the complications, 
the failure of the operation to relieve them bred a disbelief in its power 
to prevent them, and strengthened the reluctance, which seems to me in 
this connection to be sentimental rather than surgical, 4o add to the ex- 
tent of the existing lesion by operation. The reasoning consists of two 
propositions and a deduction : 1st, some patients recover without opera- 
tion ; 2d, some die after operation ; therefore, it is better not to operate 
until you are sure the patient will die if you do not. The error, in my 
judgment, lies in the failure to take into account more positively the in- 
fluence of the persistence of the primary lesions in producing the later 
symptoms which point to a fatal termination. All agree that the prin- 
cipal danger arises, not from the fracture of the bone, but from inflam- 
mation of the brain and its coverings, and admit that a depressed frag- 
ment of bone, or even a clot, may excite this inflammation. Why then 
should we hesitate to increase the extent of the comparatively indifferent 
lesion of the bone, if the much more important lesion of the brain or the 
meninges can thereby be lessened or averted ? And that it can be thus 
lessened or averted in many cases there is every reason to believe, on 
both clinical and theoretical grounds. In the other cases the primary 
injury of the viscera is so severe that the removal of the fragments will 
not prevent the development of fatal inflammation. The result seems to 
depend largely upon the condition of the dura mater ; if that is untorn 
the chances are in favor of recovery. 

In compound fractures with depression I think the safest practice is to 
remove immediately enough bone by means of the trephine, Hey's saw, 
or bone-pliers, to allow the fragments to be easily elevated or removed, 
and I think, further, that the surgeon should not be timid about removing 
the latter freely. Great caution must be used in dealing with fragments 
that have been driven through the dura mater, in order that the injury 
to the brain and the meninges may not be increased by the manipula- 
tions. Some surgeons even recommend that they should be left until 
the tissues shall have become somewhat consolidated about them by 
inflammation, but I should consider a slight increase of the laceration 
much less of an evil than the additional stimulus given by the presence 
of the fragment to the inflammatory process, which it is so desirable to 
keep within narrow bounds. The edges of the opening on the inner 
surface must be carefully examined and all projecting points removed. 
Good results have been obtained in two cases 1 by suturing the divided 
dura mater with catgut. 

In compound linear fractures, the question of interference may per- 
haps be determined by consideration of the character of the violence 
that caused the injury ; if it were severe enough or sufficiently circum- 
scribed to make splintering of the inner table probable, I should apply 
the trephine and remove at least the outer table so as to explore the 
inner one. This latter can be easily done in some cases, whenever the 
diploe is abundant and soft. The removal of a disk of bone entails no 
serious disability if the patient recovers, and it enables the surgeon to 
discover and properly treat those complications which experience has 

] W. T. Bull, in Archives of Medicine, vol. i. 1879, p. 219. 



FRACTURES OF THE SKULL. 251 

shown to be liable, if not likely, to exist on the under surface, and even 
if those complications do not exist I believe it to be of advantage by 
providing a free escape for the discharges from the dura mater and the 
surface of the fracture itself. The necessity of drainage in other 
wounds is well established, and that it may be absolutely necessary 
after linear fracture of the skull is shown by those cases in which the 
trephine or the autopsy has disclosed a purulent collection between the 
dura and the bone. It must be remembered that the fracture has al- 
ready established a communication between the meninges and the exte- 
rior, that this communication is a dangerous one, and that while the 
trephine increases it, it also removes much of its danger. A free open- 
ing into an inflamed or suppurating cavity is as beneficial as a small one 
is dangerous. 

In punctured fractures all admit the value of the trephine, and even 
those who are most inclined to delay or restrict its use elsewhere do not 
object to its early application in these cases. 

In simple fractures with or without depression the general practice is 
not to interfere unless or until severe brain symptoms indicative of com- 
pression or intra-cranial inflammation appear. The reasons for this are 
of two kinds : the frequent uncertainty of the diagnosis ; and the less 
chance of intra-cranial inflammation so long as the skin remains unbroken. 
It happens, too, not infrequently that the depression is gradually over- 
come by the constantly acting intra-cranial tension, which is estimated 
by different observers to be equal under normal circumstances to from 
eight to twenty-five millimetres of mercury and is susceptible of tempo- 
rary increase. The principal drawback to the expectative method, when 
successful, is the possibility that a source of irritation may remain which 
will lead to later intellectual or nervous disturbances, especially to epi- 
lepsy ; and it is possible that the antiseptic method may prove so efficient 
in removing the dangers incident to exposure of the cavity of the cra- 
nium that surgeons will consider it justifiable in cases of undoubted de- 
pression to cut down upon the fracture immediately with a view to pre- 
vent the possible occurrence of these late accidents, just as they now 
consider it proper to do so after these or the earlier inflammatory ones 
have made their appearance. 

A limited paralysis in a case of suspected fracture is a positive indi- 
cation for the application of the trephine, although its value is much 
greater when the paralysis is primary than when it is secondary, for the 
former indicates an existing, permanent lesion of the brain immediately 
under the seat of fracture, while the latter may be due to meningitis or 
encephalitis at some distance from the fracture. A beautiful example 
of operation followed by recovery in a case of this kind was reported by 
Lucas-Championni&re. 1 The patient was brought to the hospital uncon- 
scious with a scalp wound above and in front of the ear, and soon showed 
paralysis of the arm of the other side. The wound was enlarged and 
carried down to the bone, a fissure found and traced forward about an 
inch to a distinct fracture, the trephine applied, and a splinter pene- 
trating the dura mater removed. The weight of evidence points 

1 La Trepanation guidee par les Localisations cerebrales, Paris, 1878. 



252 FRACTURES OF THE SKULL. 

strongly to the fact that these localized paralyses are always due to lesion 
of the cortex of the brain under the anterior half of the opposite parietal 
bone, in a region, now known as the motor area, lying on either side of 
the fissure of Rolando, and corresponding to a line drawn on the scalp 
from a point in the median line 2J inches behind the crossing of the 
coronal sutures, to another one, in front of and above the ear, found by 
measuring 2-f inches directly backwards from a point on the posterior 
edge of the external angular process of the frontal bone a little below 
the upper margin of the orbit, and then 1|- inches directly upwards. 
This line is called the Rolandic line, and the motor area is in the form 
of a parallelogram an inch wide traversed centrally by it and stopping 
half an inch short of the sagittal suture. The upper third of the area 
is the centre for the lower extremity, the middle third for the upper ex- 
tremity, the lower third for the face, and the centre for articulate speech 
is at its lower anterior angle or a little below and in front of it. 

Convulsions are an indication for trephining, only when they are 
localized and persistent, and especially if they alternate with paralysis of 
the same muscles. 

In operating for the removal of depressed bone the necessary opening 
may be made in the undepressed portion with the trephine or bone pliers, 
or, if there is a projecting point, with Hey's saw. Whichever instru- 
ment is used the utmost care must be taken to avoid injury to the dura 
mater, and the graphic warning of Sir Astley Cooper, although some- 
what overstated perhaps, may be repeated to enforce this injunction. The 
surgeon should remember, he says, that " there is only the thinness of 
paper between eternity and his instrument." And for a similar reason 
I would urge the employment in the dressing of the wound of the anti- 
septic method in the most rigorous manner possible. The wound should 
be washed with the carbolic solution, the head shaved and washed with 
the same, and then completely covered with the gauze. If the wound is 
in such a position that the gauze cannot overlap it widely enough to 
insure its protection, the edge of the dressing on the narrow side should 
be fastened down with bands dipped in collodion or with adhesive plas- 
ter, or the gauze may be discarded and the wound kept covered with 
compresses wet with carbolized oil or even with the w r atery carbolic solu- 
tion. An icebag during the first few days has seemed useful. If the 
edges of the skin wound are not too much bruised they should be brought 
together with sutures, and an opening left for drainage. 

The general treatment consists of perfect rest and quiet, low diet, 
laxatives, and avoidance of stimulants. If the latter are required im- 
mediately after the accident they must be given cautiously, and discon- 
tinued as soon as reaction begins. 

Fractures of the Base. — Operative interference in these cases is rarely 
called for. Mr. Hewett mentions a case in which the roof of the orbit 
was removed through a wound above the eye, and another in which the 
trephine was applied successfully near the foramen magnum. The gene- 
ral treatment is the same as that of fractures of the vault, and some sur- 
geons use calomel freely to check inflammation. 



FRACTURES OF THE VERTEBRA. 253 



CHAPTER XIII. 

FRACTURES OF THE VERTEBRAE. 

Fractures of the vertebrae have this in common with fractures of the 
skull that most of their importance depends upon the associated injury 
of the nerve centres and trunks contained within their canal, but they 
have in addition the importance due to the function of the spine as a 
support for the head and trunk. Upon the integrity of this support 
depend not only the power of locomotion, but also grace of carriage and 
dexterity in the use of the limbs. The importance of the nerve elements 
contained within the spinal canal is second only to that of those lying 
within the cavity of the cranium ; their injury may result promptly in 
death, or in a permanent disability which maybe considered even worse, 
and even their lesser injuries may be followed by consequences in the 
way of limited paralysis which make life a heavy burden. 

The spinal cord, occupying the centre of the vertebral column, is 
efficiently protected against any external violence that is not sufficient 
to break the bones that constitute the latter, or the ligaments and muscles 
that bind those bones together ; and the column itself is constituted in a 
manner that combines elasticity and mobility with the necessary firmness 
and rigidity. The bodies of the vertebrae, increasing in size from above 
downwards in correspondence with the variations in the weight and strain 
which the different ones are called upon to bear, are composed of spongy 
tissue and separated from each other by the elastic inter-vertebral 
cartilages, and prevented from changing their positions by the interlock- 
ing of the articular processes upon the sides. The general form of the 
column is that of a tall narrow cone with a double antero-posterior curve 
which increases its elasticity, and its component parts are strongly bound 
together by ligaments and muscles allowing a range of motion which, 
while small between each pair of vertebrae, is in the aggregate consider- 
able. Mechanically, therefore, the spine is exposed to fracture by direct 
violence, like other bones, and by indirect violence through exaggeration 
or straightening of its normal curves. 

According to the statistics in the tables in Chapter I., fractures of the 
spine are relatively very rare, only 172 cases being found in the 51,938 
fractures treated in the London Hospital during a period of thirty-five 
years. Gurlt collected, however, upwards of 300 cases in which this 
diagnosis was certain and constructed from them the following tables, 
which show T the relative frequency with which the different vertebrae are 
broken and with which they occur at the different ages and in the two 
sexes : — 



254 



FRACTURES OF THE VERTEBRA. 





Fractures. 


Vertebra}. 










Fatal cases. 


Recoveries. 


Totals. » 


1st cervical 


6 





6 


2d 


11 . 


«• 


11 


3d 


12 S 


1 <y 
1 SS 


13 


4th " 


26 | 


2 w 


28 


5th " 


39 £ 


5 *- 


44 


6th " 


44 o 


2 5 


46 


7th " 


26 « 


4 


30 




■ 


— 





Total 


164 


14 


178 




. <*-. r-< 


■ —— 







O^B 








ic 9> o S ~ 






1st dorsal 


o o 2 •— _x *" 


1 


10 


2d 


8 g« S-o S3 


1 


9 


3d 


io ^!°§£ 





10 


4th " 


ii 


. 


11 


5th " 


10 


2 S 


12 


6th " 


11 i 


l s 


12 


7th " 
8th " 
9th " 


7 «■> oj 

8 e "J 


3 m g "C 


8 

8 

11 


10th " 


H £ 03 03 


6 5 £ 


17 


11th " 


19 a 5? 


G S-s 


25 


12th » 


35 g^ 


8 1? 


43 


"lower" 


o £ 3 


8 cj 


8 




oo 


— £-S 







146 O 


38 Si 


184 




cq «2 3 


o . 


i 


1st lumbar 
2d 


'84 | 5 2 
16 S ^3 


11 2 °°| 

7 £ a^ 


45 
23 


3d 


p ° p 
6 ^ - 


9 


4th " 


3 a - 1 = 


2 ^ 


5 


5th " 


M 


^ 







56 


26 


82 


Gross totals 


366 vertebrae 


78 vertebrae 


444 vertebras 




broken in 217 cases. 


broken in 53 cases. 


broken in 270 cases. 



This table shows that, comparing the different regions, fractures of 
the cervical and dorsal vertebrae are about equally frequent, 178 and 
184 respectively, while those of the lumbar vertebrae, 82, are much less 
common ; that the fatal cases of fracture of the cervical vertebrae are, 
however, considerably more numerous, actually and relatively, than 
those of the two other regions ; and, comparing the different vertebrae, 
that the fifth and sixth cervical, the last dorsal and the first lumbar are 
more frequently broken than any of the others ; and that it is common in 
fractures of the cervical and dorsal regions for more than one vertebra 
to be broken at the same time. 

In the following table the cases are arranged according to location, 
age, and sex : — 



FRACTURES OF THE VERTEBRAE. 



255 







Cervical. 


Dorsal. 


Dorsal and 
luujbar. 


Lumbar. 


Totals. 


Age. 


Fatal. Recov 


Fatal. 


Kecov 


Fatal. Eecov 


Fatal. iRecov 


Fatal. 


Recov 




M. 

4 

16 

17 

21 

7 

3 

1 

23 

92 


F. M. 


F, 


M. 

1 
15 
22 

10 
5 
2 

*8 
63 


F. 

i 

; 

7 


M. 

2 
5 

2 
6 
3 

"o 

23 


F. 

i 

i 


M. 

'4 
4 
4 
1 
1 

1 
15 


P. M. 


F. 


M. 

4 
7 
3 
4 
1 
1 

20 


F. 

'i 


M. F. 
iL 

2 .. 

.:; 

2 .. 

.. 1 

3 '.'. 


M. 

9 

42 
46 
39 
14 

7 
1 

"38 


F. 
- 

2 

G 

'4 
2 
2 

1 
1 
1 

19 


M. 

4 

12 
10 

10 

3 

io 



51 


F. 


15 to 19 . 
20 " 29 . 
30 " B9 . 
40 " 4tf . 
fiO " 59 . 
60 " 69 . 
70 " 79 . 
80 " 89 . 
"Adults" 




1 

3 

1 

i 

l 
l 

l 


4 
1 

1 


1 

"i 


1 
1 
3 
2 

'i 


'i 

•• 


Totals 


9 7 


•• 


2 8 


, 113 1 


196 


2 






108 




< 


14 






g 


5 




41 


286 



This table shows the extreme rarity of fractures of the spine in child- 
hood and old age, especially in the former, the youngest case being 
sixteen years old, the oldest eighty-three. Gurlt attributes the rarity in 
childhood to the absence of bony consolidation of the epiphyses, but I 
am more disposed to consider it the result of the greater elasticity of the 
ligaments, which, as is well known, permits a greater freedom of motion 
in most joints during childhood than during adult life. The great 
number of cases occurring between the ages of twenty and fifty years, 
and the comparative infrequency of the injury in women must be attri- 
buted to the greater exposure to the accidents which may cause fracture 
of the spine incident to the occupations of males in the prime of life. 

By a detailed analysis of the cases which furnished these tables Gurlt 
ascertains that the part most frequently fractured is the body of the 
vertebra, that is, in about two-thirds of all cases, or in more than half of 
the fractures of the cervical vertebrae, in about seven-eighths of those of the 
dorsal vertebrae, and in about all of those of the lumbar vertebras. Or, 
in general terms, fractures of the bodies of the vertebrae begin at about 
the middle of the cervical region and increase in frequency downwards. 
Simultaneous fracture of two or more vertebrae is common in the cervical 
and upper dorsal regions, less common in the lower dorsal, and rare in 
the lumbar region. Fracture of one or more of the vertebral processes 
either of the same or of adjoining vertebrae is common. 

Pathology. — The fracture of the body of a vertebra may be complete 
or incomplete ; the line of fracture may extend only partly through it or 
entirely across it, or it may be broken into several fragments, or com- 
pressed, or impacted. The line of fracture, if single, may be vertical, 
horizontal, or oblique in any direction ; the first being found almost ex- 
clusively in the cervical and upper dorsal regions, the two latter and 
multiple fractures occurring everywhere. The transverse and oblique 
fractures lie, as a rule, nearer the upper than the lower border of the 
bone, and may pass from the upper to the anterior surface, leaving the 
posterior and lower surfaces unbroken, and in these cases the upper 
fragment preserves its relations to the overlying vertebra and is displaced 



256 



FRACTURES OF THE VERTEBRA 



with it forwards and downwards, producing a change in the long axis of 
the spine characterized by an angle having its apex directed backward at 
the seat of fracture. This displacement narrows the antero-posterior 
diameter of the spinal canal and lacerates or compresses the spinal cord 



Fig. 134. 





Transverse fracture of vertebra. 



Displacement of the vertebrae causing compression of 
the spinal cord. 



Fig. 3 36. 



within it. If the line of fracture is oblique, and if fracture or dislocation 
of the oblique processes is associated with it, the displacement is inclined 
to the corresponding side either directly or by rotation. 

Compression of the body of a vertebra, similar to that observed in 
other spongy bones, is found either in combination with comminuted 

fracture or alone, and involving one or 
several vertebrae. The conditions of its 
production are not entirely known, but 
one is thought to be an unusual degree 
of softness or porosity of the bone allow- 
ing it to yield under the pressure ex- 
erted by forcible bending forwards of 
the spinal column. When this move- 
ment of forward flexion is carried be- 
yond its normal limits, either the poste- 
rior portions of the vertebrae must sepa- 
rate from each other or the anterior 
portions must approximate by conden- 
sation of the inter-vertebral disks or of 
the bone. When the latter takes place, 
as in the circumstances under considera- 
tion, the concave surfaces of the body 
of the vertebra are flattened, and its an- 
terior surface made shorter than its posterior one, the compression being 
of course more marked the greater the distance from the fulcrum (fig. 




Compression of the last dorsal vertebra. 



FRACTURES OF THE VERTEBRAE 



257 



136). The compression may be so extreme that the intervertebral disks 
above and below the affected vertebra are brought into contact with 
each other in front, the substance of the bone being partly compressed 
and partly forced out upon the sides or behind into the spinal canal 
(figs. 137 and 138), compressing the cord. With this compression may 



Fig. 13' 



Fig. 13S. 





Fracture with compression of the 3d and 4th lumbar vertebra?. 

be associated fracture or fissure of the body, and especially fracture of 
the processes of the same or the adjoining vertebra. The same shortening 
of the anterior portion of the body may be produced by splintering of 
part of the bone or by impaction of one fragment into another lying 
above or below it. This latter condition was found in four of Gurlt's 
cases, three times in the twelfth dorsal and once in the first lumbar 
vertebra. 

Fracture of the vertebral arches, according to Gurlt, is found in 
about half the cases of fracture of the cervical vertebrae, and only in one- 
seventh of those of the dorsal, and one-eighth of those of the lumbar. 
On the other hand, Dr Wyman 1 reported eleven cases of supposed frac- 
ture of the arches of the fourth and fifth lumbar vertebrae between the 
lower articular and the transverse processes, all old and ununited, four 
of the specimens being taken from ancient Indian graves. The nature 
of these supposed fractures is in doubt, and it is thought by some that 
they are merely instances of arrest of development. (See p. 270.) 

Gurlt attributes the frequency of this form of fracture in the cervical 
spine to the comparatively greater breadth and less height of the arch and 
to the absence of that protection which is furnished in the dorsal and 
lumbar regions by the larger and stronger spinous, transverse, and oblique 
processes. In fractures by direct violence, which Gurlt seems to have 
had principally in mind, this explanation would be sufficient, but Wyman's 
cases, if they are to be accepted as fractures, indicate an unsuspected 
frequency in the lumbar region and ' a different mechanism. Wyman 



17 



1 Boston Med. and Surg. Journal, Aug. 12, 1869. 



258 FRACTURES OF THE VERTEBRAE. 

calls attention to the fact that the articular processes of the lumbar 
vertebrae are widely separated from each othet, as compared with those 
of the dorsal vertebrae, and are connected only by a narrow neck, and he 
attributes the fracture to extreme backward flexion or to the shock of a 
fall upon the feet. It seems not improbable that some of the severe 
strains of the lower portion of the back which leave a more or less marked 
permanent weakness or sensitiveness of the part may be fractures of the 
arch without displacement and possibly without union. When the arch 
is broken on each side the intermediate portion bearing the spinous pro- 
cess may be driven into the spinal canal and cause fatal laceration or 
compression of the cord. Gurlt's statistics contain six such cases, affect- 
ing the fifth, sixth, and seventh cervical vertebrae. 

The sjjinous processes are broken most frequently at those points 
where they are longest and thinnest, nearly one-fourth of the cases oc- 
curring in the cervical spine, more than half in the dorsal, and about one- 
eighth in the lumbar; and often several adjoining ones are broken at the 
same time. In the dorsal region this fracture usually accompanies frac- 
ture of the body of one of the vertebrae above or below it. Isolated 
fracture of a spinous process may occur as the result of direct violence, 
or, possibly, of muscular action, and the displacement is either directly 
downwards or to one side. Sir Astley Cooper saw a case in which three 
or four of the processes were broken off by an effort to support a heavy 
wheel. The patient, a boy, passed his head between the spokes and 
took the weight upon his shoulders ; it proved too great and he fell, bent 
double. The muscles were torn upon one side, producing obliquity in the 
line of the spine at the seat of fracture, the fragments being displaced 
to the other side. There was no paralysis, and the patient recovered 
promptly with integrity of functions, but persistence of the deformity. 
Malgaigne saw a case in which the spinous process of the axis was 
broken by the passage of a cart across the shoulders and neck. The 
patient died of associated injuries, and the fracture was verified by a 
post-mortem examination. 

Fracture of the transverse or oblique processes occurs in combination 
with other fractures in about one-sixth of all cases, but is rare except in 
such combination. In the few instances in which it has occurred alone 
it was the result of gunshot injury. As a complication of other fractures 
the proportion of its occurrence for the transverse process is greatest in 
the cervical and next in the lumbar and dorsal regions ; for the oblique 
processes it is greatest in the cervical and smallest in the lumbar. Frac- 
ture of a transverse process of a dorsal vertebra may lead to fracture of 
the rib which articulates with it, and fracture of the transverse process 
of a cervical vertebra may seriously injure the vessels contained in the 
spinal canal. Fracture of an oblique process exposes to dislocation of 
the vertebra with all its accompanying dangers. 

The ligaments which bind the different vertebrae together are torn in 
fracture to an extent which varies with the severity of the injury and 
the degree of the displacement, and the intervertebral disks may be 
torn, displaced, or compressed. In rare cases the injury may be con- 
fined to the ligaments and disks, real dislocation without fracture, 
although the distinction cannot be made during life. I saw at La 



FRACTURES OF THE VERTEBRAE. 



259 



Fis:. 139. 



- 



Charite, in 1874, in the service of Prof. Trelat, a specimen of such a 
dislocation between the sixth and seventh cervical vertebrae produced by 
forced flexion of the neck forwards. The yellow ligament was entirely 
torn off and the inter-vertebral disk crushed, but no bone or process was 
broken. The patient died by asphyxia within twenty-four hours •after 
the accident. The muscles and tendons, too, are unusually torn, especi- 
ally those lying nearest the bones and ligaments ; and extravasations of 
blood form as after other fractures and extend along the cellular inter- 
spaces between the muscles and in front of the spine, sometimes into the 
posterior mediastinum, and sometimes into the retro-peritoneal tissues, 
surrounding the kidneys and the iliacus and psoas muscles. Ecchymoses 
may appear on the face or chin after fracture of the cervical vertebrae, and 
as low even as the loins in other cases. If the displacement is such as to in- 
jure the cord large collections of blood may form within the spinal canal, and 
in some fractures of the cervical vertebrae the vertebral artery is divided. 

The spinal cord, the diameter of which is considerably less than that 
of the canal in which it lies, is suspended within the 
dura mater, which is itself loosely connected with the 
bones and separated from direct contact with them in 
most places by a rich venous plexus. The medullary 
portion of the cord ends at the first or second lumbar 
vertebra, and its lower portion is enveloped by the 
numerous nerve trunks which pass downward to form 
the cauda equina and the lumbar and sacral plexuses. 
The cord is injured directly only when the lumen of 
the canal is considerably encroached upon by the dis- 
placement of a fragment or of a vertebra, but it can 
be compressed by extravasated blood or by inflam- 
matory exudations. Extravasated blood usually lies 
between the dura and the bone behind or on the sides, 
and is furnished by the veins just mentioned. The 
cord itself is seldom the seat of any considerable 
hemorrhage even when it has been badly crushed or 
lacerated. Occasionally the cord is penetrated by a 
sharp fragment, but usually the dura mater is untorn 
and the cord is crushed between the anterior portion 
of one fragment or vertebra, usually the lower, and 
the posterior portion of another, usually the upper. 
This crushing presents all degrees, from a slight flat- 
tening to complete rupture either structural or func- 
tional by disorganization of the tissues. 

Figure 139 represents the lower portion of the 
spinal cord after simple transverse fracture of the first 
lumbar vertebra. The patient died on the nineteenth 
day. * The spinous and left transverse processes en- 
croached upon the cord which was lacerated at the 
lumbar and dorsal junction. The membranes were 
entirely torn across, and " the tubular nerve fila- 
ments have been curiously dissected out by the pus Laceration of the cord, 
in which the cord was bathed." < u \ s ; Med " aud Surs ' 

MlSt.) 




260 FRACTURES OF THE VERTEBRAE. 

Etiology. — Besides those causes, general and local, mentioned in 
Chapter IV., which predispose to fractures m general, there are two 
local ones which lead occasionally to fracture of the spine — aortic aneur- 
ism and ankylosis following spondylitis deformans and due to the 
growth of osteophytes or ossification of the ligaments and intervertebral 
disks. The first acts by causing absorption of the bone, the loss of sub- 
stance sometimes involving almost the entire body of the vertebra and 
opening the spinal canal ; this allows the column to bend forward, and 
brings a strain upon the articular processes which they are not prepared 
to meet and under which they break. The second, ankylosis, favors frac- 
ture, especially when it involves several adjoining vertebrae, by the 
rigidity which it creates, and the powerful fracturing leverage thus 
furnished to movements of flexion even within the normal range. In 
short, it transforms a row of short bones movable upon each other into 
a rigid long bone. 

The immediate causes are muscular action and external violence. The 
former is exceedingly rare ; one case has been already mentioned in 
Chapter IV., in which the neck was broken by the forcible bending of 
the head backward in an effort to save it from striking against the 
ground when the patient was diving and found the water less deep than 
he had supposed. It is doubted by some if such are really cases of 
fracture by muscular action, and it is thought that although the face 
was not bruised, and the patient declared it had not struck the ground, 
yet it might have done so. Schede, 1 however, reported at the Tenth 
Congress of the German Gesellschaft iiir Chirurgie a case which seems 
unquestionable, for the patient's hands struck the ground and protected 
the head. The patient survived three weeks. Schede says three analo- 
gous cases have occurred : in each the fracture was of the fourth or fifth 
cervical vertebra. An undoubted case of fracture by muscular action 
is quoted by Gurlt from Lasalle ; the patient was a lunatic who, in his 
efforts to free himself from a chair, in which he had been bound, bent 
his head forcibly backwards and forwards and produced a dislocation 
between the fifth and sixth cervical vertebrae with fracture of several 
processes. In other cases in which the patients have tried to lift a 
heavy weight by placing the shoulders under it and then, finding them- 
selves unable to support it, have fallen, it is not always easy to dis- 
tinguish between the effects of the muscular effort and those of the fall- 
ing weight. 

Of 286 cases tabulated by Gurlt according to the character of the 
fracturing force, 176 were caused by a fall from a height, and 50 by the 
fall of a heavy body upon the patient. The cases in which the action is 
exerted directly upon the bone that is broken are -relatively few in num- 
ber, and the great majority are fractures by indirect action. To under- 
stand the mode of production of these latter it must be remembered that 
the spinal column is like a many-jointed rod possessing a flexibility 
which varies at different points. This flexibility, which is largely due 
to the elasticity of the inter-vertebral disks, is restricted by the inter- 
locking processes and ligaments, and its variations in extent and direc- 

> Supplement to Ctblatt fur Chirurgie, 1881, No. 20, p. 33. 



FRACTURES OF THE VERTEBRA. 261 

tion are due to the differences in the form and relations of the articular 
processes. The range of motion is greatest in all directions in the cer- 
vical portion and is least in the dorsal portion, especially in the antero- 
posterior direction, while the lumbar portion allows free flexion but 
almost no rotation. This combination of different degrees of flexibility 
seems to account for the greater frequency of fracture at certain points, 
according to a mechanism pointed out by Sir Charles Bell who compared 
the spine to a jointed fishing-rod which breaks, when over-bent, close to 
a rigid joint rather than in the centre of one of its long elastic pieces. 
In like manner the spine breaks most frequently at or near the points 
where a flexible portion adjoins a comparatively rigid one, for example 
at the union of the cervical and dorsal and of the dorsal and lumbar 
portions. These points correspond to the ends of the normal curves of 
the spine rather than to their centres. 

Indirect fracture takes place usually by forced flexion beyond the 
normal limits, whether the force is exerted by a fall upon either end, 
by the action of a heavy body, or by flexion of the trunk ; and it has 
been shown by Philipeaux's experiments upon the cadaver that the 
forced bending forwards of the trunk causes most commonly an oblique 
fracture of the body of the eleventh or twelfth dorsal vertebra, the line 
of fracture running forwards and downwards. In only a few of the 
cases collected by Gurlt was the fracture caused by the simple flexion of 
the trunk ; in most the mechanism was more complicated, by the fall 
either of the body from a height or of a weight upon it, or by an una- 
vailing effort to lift or resist a weight, the fracture taking place in the 
latter case at some distance from the point where the weight rested or 
struck ; and in one unique case the atlas was broken in rough play, the 
patient being seized by the brim of his hat, and his head forcibly bent 
from one side to the other while he was forced down upon a seat. 

The fractures by direct violence are few, only fourteen in Gurlt's 
collection ; and the force was exerted in almost every case upon the 
posterior portion of the column, fracturing first the spinous processes or 
the arches, and then in some cases the bodies of the vertebrae, or caus- 
ing a dislocation. In most of these cases the violence was a blow, and 
in only one was the fracture compound, a fracture of the neck caused 
by two cows walking over the patient as he lay in a ditch. 

Symptoms and Diagnosis. — The symptoms of fracture of the spine 
vary with the position and the portion of the vertebra involved, and 
therefore need a separate and detailed consideration in connection with 
the different groups of fractures. But there are certain general symp- 
toms common to most w T hich may first be mentioned. After the first 
shock of the injury, which usually passes off without permanent impair- 
ment of the intelligence, the patient complains of a localized pain at the 
seat of fracture increased by manipulation or movements. There is 
usually a recognizable deformity consisting of a change in the direction 
of the spine, a more or less marked angular projection backwards with 
or without swelling of the surrounding soft parts ; crepitation can some- 
times be made out by the surgeon, but more commonly it is appreciable, 
if at all, by the patient himself when his body is moved. The most 



262 FRACTURES OF THE VERTEBRJS. 

important and constant symptom is paralysis, motor and sensory, more 
or less complete, of the limbs and the portion of the body lying below 
the fracture. If complete its upper limit is usually sharply defined by 
a line crossing the trunk and corresponding to the adjoining limits of the 
regions supplied by the nerves that leave the column immediately above 
and below the point at which the cord has been injured. The conse- 
quences of this paralysis, if it involves the abdominal muscles, bladder, 
and rectum, are retention of urine and feces, followed by incontinence 
of one or both, by alkaline fermentation of the former, and cystitis. 
Respiratory difficulties, sometimes severe enough to cause death, appear 
when the fracture involves the upper portion of the spine, the result of 
the paralysis either of the abdominal muscles or of the diaphragm. 
There is also great tendency to sloughing at all points of pressure 
within the paralyzed region, especially over the sacrum, trochanters, 
the tuberosities of the ischii, and along the back. The sloughs appear 
promptly, sometimes within two or three days, are usually symmetrical, 
and often hasten death even if they are not its immediate cause. 

The paralysis is usually so complete that even reflex contractions can- 
not be excited, and the muscles quickly lose their contractility under 
electrical stimulus. If the paralysis of sensation is incomplete, so that 
pinching can be only slightly felt, the ability to distinguish between heat 
and cold may exist unaltered; and occasionally there is hyperesthesia 
of the surface so marked that the slightest touch causes pain, and in a 
few cases sharp shooting pains have been observed in the course of the 
main nerve trunks of the legs, excited by slight movements of the trunk 
or of the limbs, but not by direct pressure upon the spine. This ex- 
treme sensibility has been attributed to the irritation of splinters press- 
ing upon the spinal cord, but the opinion lacks anatomical proof. It 
is also a common symptom of commencing improvement, appearing with 
the return of reflex irritability and muscular twitchings or spasms. 

Tonic or clonic muscular spasms are observed in the anus, and more 
rarely in the legs and body, and may be excited by a great variety of 
causes, such as irritation of the surface by a touch or a current of cold 
air, or change of position of the limbs or of the body. 

The temperature of the paralyzed portions shows changes which are 
not always the same, being sometimes increased, sometimes diminished, 
and sometimes unaltered. Marked elevation of the temperature has 
been observed in experiments upon animals after complete or partial 
division of the spinal cord in its upper portion, and the same has been 
noticed clinically. Gurlt quotes a case from Sir Benjamin Brodie, 
in which, after fracture of the fifth and sixth cervical vertebrae with 
slow diaphragmatic respiration, small pulse, and livid countenance, 
the temperature between the scrotum and thigh rose to 111° Fahr. ; 
the patient died in twenty-two hours. I saw in Prof. Gosselin's wards 
at La Charile in 1875 an example of the same injury, fracture of 
the fifth and sixth cervical vertebrae caused by a fall while turn- 
ing a somersault, with forced flexion of the head upon the chest, in 
which death by asphyxia followed in twenty-four hours, the temperature 
rising to 106°. A symptom in this case and in the similar one of Tie- 
lat's above mentioned was the expectoration towards the end of life of a 



FRACTURES OF THE VERTEBRAE. 263 

good deal of blood, and at the autopsies the lungs were found very much 
congested. In Gosselin's case the spinal cord was compressed by the 
displaced vertebra and congested, but not divided. A very remarkable 
case of high temperature following injury of the spine was reported by 
Mr. Teale. 1 The elevation was constant for several months, the maxi- 
mum being 122° Fahr. The patient recovered. 

Persistent and obstinate vomiting has been observed in some cases, 
most frequently after fracture in the lower cervical portion, and at the 
autopsy of one such case the mucous membrane of the stomach showed 
numerous ecchymoses, and there was half-digested blood in the cavity of 
the viscus. In two cases this vomiting, which was accompanied by com- 
plete constipation, became fecal, and remained so until a movement of 
the bowels was obtained. In both cases the fracture was of the cervical 
spine, and the paralysis was complete in the lower limbs and almost com- 
plete in the arms. 

Priapism, more or less complete, was observed, according to Gurlt, in 31 
of 96 cases of fracture of the cervical and two upper dorsal vertebrae, 16 
times in 133 cases ot fracture between the third dorsal and second lumbar 
vertebrae, and never in fracture below the latter. It appears promptly, 
usually on the first or second day, and seldom lasts longer than a fort- 
night. Notwithstanding the insensitiveness of the penis it may be caused 
or increased by the use of the catheter. On the other hand, in one case 
the erect organ became relaxed as soon as the catheter had passed over 
half the length of the urethra. Ejaculations are very exceptional, there 
being only lour instances in Gurlt's collection, all of them in cases of 
fracture of the cervical spine; in one case they were continuous, in 
another they were excited by the introduction of a catheter. 

Fracture of Atlas and Axis. — The intimate relations existing between 
these two bones and the medulla oblongata, and their position above the 
root of the phrenic nerve as well as above those of the other nerves sup- 
plying other muscles which aid in respiration, make their injury especi- 
ally dangerous, and have probably led to the generally received opinion 
that their fracture is, as a rule, immediately fatal. Gurlt's cases show, 
however, that this opinion is not correct, for in the eleven in which the 
nature of the injury was demonstrated by the autopsy, death occurred 
immediately in only two, and in only two others within an hour after the 
injury was received. In the other cases the patients survived for a con- 
siderable length of time, thirteen clays in one, although some of them at 
the last died suddenly, apparently by displacement of the vertebrae due 
to incautious movements. The fractures were all caused by external 
violence, sometimes slight, as a fall from the bed while trying to reach 
down to the floor. 

The parts broken in ten of these eleven cases were : the odontoid pro- 
cess alone once ; the odontoid process and posterior arch of the atlas three 
times; the posterior arches of the atlas and axis three times; the pos- 
terior arch of the axis alone once ; the spinous process of the axis twice. 
In six of the cases there was associated fracture of the cervical or dorsal 
vertebrae, and in no case was the transverse ligament torn. Figure 140, 
taken from a specimen in the museum at Braunschweig, shows a fracture 

1 Lancet, March 6, 1875. 




264 FRACTURES OF THE VERTEBRJ. 

of the superior articular surface of the axis. The patient was twenty-four 

years old, and died in a few hours after falling out of a wagon upon his head. 

Dr. Chas. T. Hunter 1 explains the frequency of fracture of the axis, 

as compared with that of^the atlas, or 
Fi S- 14 °- with rupture of the transverse ligament, 

by the fact that the structure of the 
body of the axis is comparatively spongy, 
and he shows that its weakest point is 
about one centimetre below the neck of 
the process. 

The symptoms of this fracture are so 
variable and so indefinite and have so 
much in common with simple dislocation 
of one bone upon the other, or of the 
atlas upon the skull, that the diagnosis 
is extremely difficult. On the one hand, 
the patient may die instantly; on the 
other, he may survive a longer or shorter 
?racture throng: time > e ither completely paralyzed or 

surfaces of the axis. (Gurit.) presenting no important symptoms, and 

then die suddenly by displacement of 
the fragments or gradually by extension of the symptoms, or in conse- 
quence of other injuries, or, if the diagnosis in some such cases may be 
accepted, may even get well. The symptoms of local pain and stiffness 
of the neck are too indefinite to be of any service, and paralytic symp- 
toms may be entirely absent, as in Gurlt's second case where the patient 
walked for two hours after the accident to reach home and developed no 
paralysis until the following day. Death took place suddenly on the 
eighth day, and the autopsy showed fracture of both arches of the atlas 
and of the odontoid process. 

The symptoms in those of Gurlt's eleven cases which survived long 
enough to present any, or in which any are recorded, were complete 
paralysis of all the parts below the fracture in some, partial paralysis 
in others, only a slight diminution of sensibility in the left arm in one, 
pain in the neck or occiput in six, rigidity of the neck in most, absence 
of recognizable deformity in all, distinct crepitation in one, and falling 
forward of the head upon the breast in one. All of these symptoms — 
pain, rigidity, paralysis, sudden death — may be the result of dislocation 
as well as of fracture ; and as dislocation has in addition no characte- 
ristic, general or local, symptoms which serve to distinguish it the differ- 
ential diagnosis must usually remain in doubt. 

Fractures of the lower five Cervical and first two Dorsal Vertebrae. 
— The special characteristics of fractures of this region are due to the 
inclusion within it of the roots of the phrenic nerve and brachial plexus. 
The former passes out through the intervertebral foramen between the 
third and fourth cervical vertebrae, either coming from the fourth cer- 
vical pair alone, or receiving branches also from the third and fifth 
pairs. The brachial plexus is formed by the four lower cervical and 

1 Holmes's System of Surgery, Am. ed., vol. i. p. 808. 



FRACTURES OF THE VERTEBRAE. 265 

the first dorsal pairs. Consequently, if the fracture is accompanied by 
displacement of the fragments and injury to the spinal cord, paralysis 
of the upper limbs also is caused, and if the fracture is high enough in 
the region to involve the phrenic nerve directly or by extension death 
follows promptly, preceded by the respiratory symptoms peculiar to 
lesion of this nerve. As the tables quoted from Gurlt show, fractures 
are more common in this region than in any other, and this frequency 
is due especially to the numerous fractures of the fifth and sixth verte- 
brae, which in each case are far in excess of those of any other vertebra 
except the last dorsal and the first lumbar, 

Here too, as after fracture of the atlas and axis, are found cases in 
which the patients present only symptoms of paralysis for a longer or 
shorter time, and then die suddenly of asphyxia in consequence of some 
accidental or intentional movement of the head, which probably causes 
compression of the phrenic nerves by displacement of the fragments. 
Gurlt's tables contain 7 of these sudden deaths ; in 4 of them the imme- 
diate cause was not known or is not indicated ; of the remaining 3 deach 
was caused in one by the barber who turned the patient's head to one 
side while shaving him, in another by the patient's wife who passed her 
hand under his neck and tried to raise him, and in the third by the 
patient's daughter, by putting her arms about him to embrace him. 
Death was accompanied in most of the cases by slight convulsions, and 
took place at periods varying from twelve hours to twenty-three days 
after the receipt of the injury. 

The paralysis in fractures of the portion of this region below the 
fourth cervical vertebra shows many variations. From the relations of 
this part to the brachial plexus it might be expected that paralysis of 
the upper limbs would be a constant symptom, excluding those cases in 
which there is no displacement, but Gurlt's tables show this paralysis to 
have been present in less than one-fourth of the cases, that in the major- 
ity complete paralysis of the lower portion of the body extended upward 
at first only to the middle of the breast, the second rib, rarely to the 
neck, clavicle, or shoulders, and sometimes not even to the umbilicus, 
although it often advanced to a higher point later in the progress of the 
case. Paralytic symptoms appeared in the arms, as a rule, either later 
on the day of the accident or on the following day. The paralysis may 
be complete in one arm and partial or absent in the other; it may be 
complete of motion and incomplete of sensation, or the reverse ; it may 
be limited to the arm or to the forearm ; or the injury to the nerves 
may be evidenced by abnormal sensations, such as numbness or prick- 
ling in the limb. Hypersesthesia affecting the whole or part of the 
limb is occasionally observed, and is sometimes associated with sharp, 
lancinating, continuous, or intermittent pain, which may be spontaneous 
or may be excitedor increased by the slightest touch of the surface. 
Tonic or clonic spasms are seen somewhat more frequently than hyper- 
esthesia, sometimes limited to the arms alone, sometimes involving other 
muscles also. 

An important consequence of the paralysis is the change in the respi- 
ratory act due to the withdrawal of the aid of the accessory muscles 
when the phrenic nerve is uninjured. As a consequence of the paraly- 



266 FRACTURES OF THE VERTEBRAE. 

sis of the intercostal and abdominal muscles, inspiration is effected by 
the diaphragm alone, and expiration by the weight of the abdominal 
walls and viscera which sink back to the positions from which they have 
been displaced by the contraction of the diaphragm. As, the expiration 
is thus purely passive the patient cannot sneeze or cough strongly, and 
as he is thus prevented from cleaning his lungs of the mucus which 
collects in them it gives rise to plentiful moist lales. If the phrenic 
nerve shares in the injury the diaphragm acts very slowly, perhaps not 
oftener than twice or thrice in the minute, the breathing is noisy or 
sighing, and the shoulders may be slightly raised at each inspiration. 
Sometimes a change in the position increases or diminishes the difficulty 
by modifying the pressure upon the cord. A noticeable slowing of the 
pulse accompanies this defective respiration. The voice becomes weak, 
and speech slow and difficult because of the insufficient volume of air; 
there is a peculiar coloring of the face due to defective decarbonization 
of the blood, to which Bransby Cooper first called attention, and finally 
towards the end of life delirium or coma supervenes. 

The local symptoms are usually few and obscure, often nothing more 
than the pain that is felt at the seat of fracture and is increased by pres- 
sure or motion. In several cases, according to Gurlt, it was impossible 
to detect even after death any deformity or crepitation. In other cases 
there are positive objective signs: an abnormal projection or depression 
of one or more spinous processes, an irregularity on the posterior wall 
of the pharynx produced by the displaced body of a vertebra, lateral 
displacement of one or more spinous processes, and possibly crepitation 
or abnormal mobility. 

The position and mobility of the head vary greatly in different cases. 
In some cases they show nothing abnormal, in others the head can be 
moved freely to either side, but not forward or backward, and in others 
it is held firmly fixed in some one position and any attempt to change 
that position causes pain. This rigidity is due not to change in the rela- 
tions of the articular surfaces, but to the involuntary spasmodic contrac- 
tion of the muscles which is nature's method of preventing the infliction 
of pain by movement of the parts. 

It is apparent that the diagnosis of fracture of this region may be 
difficult or impossible. The most that can be clone in many cases is to 
recognize approximately the seat of the injury. Thus, paralysis or 
symptoms of irritation in the arms, even if they first appear alter some 
delay, indicate a lesion above the second dorsal vertebra, although in a 
few exceptional cases this symptom has existed when the injury was 
lower on the spine, and was then due probably to an associated brain 
lesion or a large collection of blood within the spinal canal. If all local 
and functional signs are absent the diagnosis is of course impossible, and 
the real nature of the injury may be entirely overlooked until the pro- 
gress of the inflammation or a chance displacement of the fragments brings 
it to light. 

A remarkable instance of this form w T as reported by Mr. Simon 1 under 
the title of latent fracture of the spine. A girl fell down an embank- 

1 Surgical Observations, p. 145 ; quoted in Holmes's Syst. of Surgery, Am. ed., vol. 
i. p. 795. 



FRACTURES OF THE VERTEBRAE. 267 

merit and injured her neck. She afterwards walked three miles and 
continued at her occupation in a factory for eleven days. On the 
fifteenth day she was admitted to St. Thomas's Hospital with vague 
complaints of pain and tenderness in the neck, but without deformity or 
paralysis of motion or sensation. Early on the following day she com- 
plained of numbness and twitching in the limbs, especially the lower 
ones, and by the evening voluntary motion was entirely lost in the legs 
and almost so in the arms, and sensation was impaired in both. There 
was also high fever with delirium and tympanites. She died on the 
third day after admission, the eighteenth after the fall. 

The autopsy showed a horizontal fracture of the body of the seventh 
cervical vertebra, gaping a little in front, but with no displacement. The 
vertebral canal contained, outside the dura mater, throughout its entire 
length from two inches below the foramen magnum, a large quantity of 
pus which had spread somewhat along the tracks of the nerves at the 
inter-vertebral foramina, and had actually emerged through the foramen 
between the first and second dorsal vertebras. There was no softening 
or change recognizable by the microscope in the spinal cord. 

A similar case is reported by Erichsen. 1 A woman was admitted into 
University College Hospital suffering from the effects of a fall upon the 
back, the symptoms attending which were obscure. There were no head 
symptoms, no head injury, and no paralysis; but she complained of pain in 
the neck, and kept the head, fixed immovably. A few days after admis- 
sion, whilst sitting up in bed, she was startled by a noise, turned her 
head suddenly to learn the cause, and fell back dead. 

At the autopsy it was found that the spinous process of the fifth 
cervical vertebra had been broken off at its root. By the sudden move- 
ment it was forced into the space between that and the adjoining ver- 
tebra, compressed the cord, and caused death. 

In two of Gurlt's cases, fractures of the fifth and sixth cervical verte- 
brae, the vertebral artery on one side was torn, with free escape of blood 
between the muscles and into the vertebral canal. 

The prognosis is extremely unfavorable. Gurlt's tables contain 96 
fatal cases, and only 8 which ended in recovery, and in one of these the 
symptoms reappeared after a fall and the patient died in consequence. 
In one-third of the cases death took place within the first four days ; in 
20 between the fifth and twelfth days : in 11 between the thirteenth and 
thirty-sixth ; and in one case the patient survived five months. 

Fractures of the lower ten Dorsal and first two Lumbar T r ertebrce. 
— This region includes another point at which fractures are very com- 
mon, the lower dorsal and the first lumbar vertebrae. Its position below 
the original of the brachial plexus prevents the involvement of the arms 
in the paralysis except in rare cases where this unusual extension is due 
apparently to the spread of inflammatory softening of the cord or to the 
pressure of extravasated blood. Paralysis of the lower limbs, the blad- 
der, and rectum, which is one of the common results of fracture in this 
division as well as in the higher ones, may be entirely absent at the 
beginning, especially after fracture of the second lumbar vertebra, or, 

1 Concussion of the Spine, p. 50. 



268 FRACTURES OF THE VERTEBRAE. 

more frequently, maybe incomplete, the motor paralysis being as a rule 
more marked than the paralysis of sensation. The latter may extend as 
high as the lower part of the heart, or may stop at the groin, and some- 
times even does not reach above the lower part of the thigh. A common 
result of the paralysis is the immediate retention of urine and feces, 
followed, as before mentioned, by incontinence and by alkaline decom- 
position of the urine and cystitis. This incontinence persists until death 
takes place or improvement begins. The disturbance in the function of 
the bowels aided by the flaccidity of the abdominal muscles produces 
tympanites which makes its appearance usually within a day or two and 
may be sufficiently marked to interfere with respiration by crowding the 
diaphragm upwards and opposing its contraction. 

In other cases, even of apparently severe injury to the body of a 
vertebra, there may be an entire absence of paralytic symptoms and 
even of those of meningeal irritation. Erichsen 1 narrates the case of a 
young man who was caught in a turn-table which doubled his body for- 
wards and caused intense pain in the back. After remaining a few 
weeks in hospital he was discharged. His symptoms were inability 
to stand upright or to walk for more than half an hour, because of the 
pain it caused in the back and under the ribs. The spinous processes 
of the tenth and twelfth dorsal vertebras projected, and there was a dis- 
tinct depression between them. The spinous process of the eleventh 
dorsal was broken off and twisted so as to lie directly across to the left 
side. When lying on his back the patient was unable to rise without 
the "aid of his hands. The legs were wasted, their sensibility and reflex 
irritability normal. No tinglings, no paralysis of the sphincters, no 
sensation of a cord about the body. Muscular reaction to the interrupted 
current equal in all muscles. 

Another case, in which symptoms were almost entirely absent, was 
reported by Dr. Basling in the Lancet, Feb. 4, 18&2, page 186. The 
patient, a middle-aged man, had his back forcibly bent while driving 
under an archway. The only symptoms were slight pain in the back 
and increase of the interval between the ninth and tenth dorsal spinous 
processes. He died on the nineteenth day of injuries inflicted at the 
same time upon the thorax. " The pedicle on both sides of the tenth 
dorsal vertebra was broken close to the body, and the spine was tilted a 
little downwards ; the fracture also extended transversely through the 
middle of the body of the vertebra without causing displacement, and 
without rupturing the anterior or posterior common ligaments. On the 
external surface of the dura mater, opposite the seat of fracture, there 
was a deposit of lymph the size of a shilling. The other membranes 
and the spinal cord itself were quite healthy." 

The diagnosis is aided by objective symptoms, which are more marked 
and distinctive than those found after fractures of the upper portion of the 
column, because as the fracture in the great majority of the cases in- 
volves the body of the vertebra, and is comminuted or accompanied by 
displacement, there is usually a recognizable deformity consisting in an 
angular change in the long axis of the spine, with projection of the spin- 

1 Concussion of the Spine, p. 123. 



FRACTURES OF THE VERTEBRA. 269 

cms process of the broken vertebra or of the one immediately above it. 
This change in the position of the spinous process is sometimes so marked 
that the finger can be pressed deeply in between it and the next lower 
one. 

The prognosis, as regards both life and recovery of function, is more 
favorable than after fracture at a higher point. Gurlt's statistics con- 
tain 145 cases, of which 39 recovered more or less completely ; in 18 
additional ones the patients survived more than three months, with a fair 
prospect of recovery, but died in consequence of some complication that 
had no necessary connection with the fracture. In 23 of the fatal cases 
other severe injuries or complications were present, and apparently 
caused death. Of the 83 fatal cases which remain after excluding these 
23, 1 died in the first twenty-four hours, 33 in the first month, 23 in the 
second, 8 in the third, and 2 in the fourth ; in 16 the patients survived 
for periods varying between four and fifteen months. 
i Fractures of the loiver three Lumbar Vertebra? . — Fractures of this 
portion of the spine are, according to Gurlt's statistics, exceedingly 
rare. 1 The absence of paralytic .symptoms and recognizable displace- 
ment would make the diagnosis during life practically impossible. 

As this portion of the spinal canal contains only nerve trunks, which 
are better fitted by their texture and comparative independence of each 
other to resist or escape damaging pressure by displaced fragments than 
the spinal cord itself is, paralysis may be absent even when the dis- 
placement is marked; in some cases it has been complete, both of motion 
and sensation, over the limbs and abdomen. Mr. Shaw 2 observed four 
cases of fracture in this region in which there was total absence of 
paralysis ; in the first the displacement was so great that the spinous 
and transverse processes projected visibly, the spine could not be straight- 
ened, and the patient's body remained permanently much bent, yet 
motion and sensation were retained from the first. In another there 
was relatively greater prominence of the displaced vertebrae fourteen 
years afterwards than at the time of the accident, when the patient was 
eight years old, u but the column was, on the whole, nearly straight, 
and his muscles were powerfully developed." In another case Mr. 
Shaw "found the trunks composing the cauda equina lifted one-third of 
an inch on a bridge of bone formed by the displacement of a fractured 
lumbar vertebra ; but they were in no degree compressed, and showed 
scarcely any trace of injury." 

The patient may, however, be unable to walk in consequence of the 
loss of support occasioned by the fracture, or he may walk only feebly 
and in a bent posture. But if union takes place, even if the deformity 
persists, he may be as strong and capable as before. In short, the 
prognosis is favorable as regards both life and function. 

1 If the specimens of supposed ununited fracture of the arch of these bones, which 
have been found upon the dissecting-table, in museums, and in old Indian graves, are 
accepted as such, they raise the question whether similar fractures are not more com- 
mon than has been supposed, and whether they may not be present, without dis- 
placement, in some of the severe, so-called strains of this region. I incline to the 
belief, however, that they are specimens of arrest of development. 

2 Holmes's System of Surgery. Am. ed., vol. i. p. 804. 



270 



FRACTURES OF THE VERTEBRAE. 



Fiff. 141. 



Course and Terminations. — The course and terminations of fracture 
of the spine, with their many variations as regards both the life and 
principal functions of the patient, have been indicated in the preceding 
paragraph ; we have now to consider the changes effected in the broken 
bone by the process of repair, and to describe some of the later symp- 
toms with mor« detail. 

Repair takes place as after fracture of other spongy bones, that is, by 
a callus which may remain fibrous or become bony, and may be larger or 
smaller according to circumstances. As the displacement cannot be 
reduced the fragments must unite, if at all, in the positions in which 
they are left by the accident, and although the normal relations may be 
thus notably altered and the union remain fibrous the solidity is quite 
sufficient. The spinous processes frequently unite only by fibrous tissue 
and remain movable ; and sometimes they show a real pseudarthrosis, 
with capsular ligament and smooth surfaces, although it is questioned by 
some if this condition has originated in a fracture. In fractures that 
have been healed for a long time is found the same absorption of pro- 
jecting angles and surfaces which has been noticed in connection with 
other fractures, and this absorption is especially marked in the bodies of 
the vertebrae. If several adjoining vertebrae are broken at the same 
time the intervertebral disks disappear in part by absorption, and the 

remaining portions undergo partial or 
complete ossification, uniting struc- 
turally with the vertebrae, and thus 
forming a more or less extensive, rigid, 
bony mass (fig. 141). The length of 
time required for consolidation ap- 
pears to be greater than for that of 
other spongy bones, probably because 
the immobility of the parts is not so 
complete. 

A number of instances, of complete 
pseudarthrosis have been recorded, 
and their origin differently interpreted. 
Gurlt has collected 21 such cases : 
1 of the odontoid process, 4 of the 
spinous processes of the cervical, dor- 
sal, and lumbar vertebrae, and of the 
sacrum, 3 of the transverse processes of 
lumbar vertebrae, 11 of the arches of 
lumbar vertebrae, and 2 of the side of 
the upper false vertebra of the sacrum. 
Meckel considered the 11 cases in- 
volving the arches of lumbar vertebrae 
as instances of arrest of develop- 
ment, comparing them to the vertebrae 
of some reptiles, which consist nor- 
mally of a separate body and arch, 
and in which many of the processes also remain ununited. Otto opposed 
this view, because the position of the false joint does not correspond to 




Ankylosis by fusion of the vertebr; 
fracture. 



after 



FRACTURES OF THE VERTEBRJS. 271 

that of the line between the diaphysis and epiphysis, and Wyuian, 1 who 
reported 11 additional cases, and did not know of these earlier ones, 
held the same opinion for the same reason. Gurlt accepts Meckel's 
opinion concerning the arches of the lumbar vertebrae, and claims that it 
is probably true also of the other cases. His reasons are that there is 
no trace of injury to other parts, and that it is known that fracture lim- 
ited to a vertebral arch, a spinous or transverse process, is exceedingly 
rare; -that most of the cases relate to the lowest lumbar vertebne, 
fractures of which, of any kind, are rare, and in the case of the fifth 
unknown ; and that the identity of the position of the joint in all corre- 
sponding cases, and its perfect structure, point strongly to an arrest of 
development, and are incompatible with a fracture by external violence. 
Wyman says of his specimens that " the opposing surfaces of bone have 
the usual roughness, and in some instances the neighboring parts are the 
seat of irregular bony deposits. In two the surfaces have been worn 
smooth by mutual friction." Sir Charles Bell 2 mentions and describes 
another, apparently lumbar, vertebra, which he thought " must have suf- 
fered violence of the nature of a diastasis in childhood." " The spinous 
process is separated [on each side] from the transverse process, so as to 
divide the ring which forms the canal of the spine. The surfaces are 
rounded and smooth, showing that they were united by ligament and 
permitted a certain motion." 

Suppuration at the seat of fracture, which is very rare in other bones, 
seems to be more common after simple fracture of the spine, and is at- 
tributed by Gurlt to the greater complexity of the anatomical conditions 
and to the less perfect immobility maintained during the progress of the 
case. His statistics contain eight cases in which, excluding instances of 
suppurative meningitis, more or less pus was found after death at the 
seat of fracture ; in four of the cases the abscess was large, and its walls 
formed in part by the unbroken ligaments, in one of them the wall of 
the abscess had ossified. Usually the intervertebral disks are partly 
destroyed, the 'articular surfaces eroded, and sometimes the bone cari- 
ous. In most cases the suppuration was limited to the fracture, but in 
one the pus had made its way out by several channels through to the 
muscles and tendons, and had collected in the back. 

Inflammation of the end or its envelopes as a consequence of injury 
to the spine is comparatively infrequent ; when it occurs it may be con- 
fined to the outer side of the dura mater, creating adhesions between it 
and the bone, or ending in suppuration, or it may occupy the inside of 
this sheath, and then be the result either of injury to the cord or, more 
rarely, of a spinal meningitis without injury to the cord or any paralytic 
symptoms. In the latter case, the first symptoms are those of irritation 
in the form of spasmodic twitchings in the limbs, and are followed by 
paralysis due to compression of the cord by the increasing exudation. 
With this may come delirium, repeated chills, and sweating. Abscesses 
within the substance of the cord are extremely rare ; only one instance 
is contained in Gurlt' s statistics. As to the recovery of the cord after 

1 Boston Med. and Surg. Journal, Aug. 14, 1889. 

2 Injuries of the Spine, pp. 28 and 83, and plate iii., figs. 5 and 6. 



272 FRACTURES OF THE VERTEBRAE. 

injury, with restoration of function, nothing definite is known beyond 
the fact that a number of autopsies made at various periods after injury 
have shown the cord more or less completely divided, or reduced to pulp 
at the compressed part, or replaced by fibrous tissue. There is nothing 
to prove that a disintegrated portion can be restored, or that divided 
cords can be reunited, and it is not easy to see how proof of such a fact 
could be furnished except by experiment. In those cases in which 
paralysis has disappeared after a time, it is impossible to know exactly 
what was the nature of the lesion of the cord that caused it. 

The troubles created by paralysis of the bladder are very serious, and 
often hasten a fatal termination. They begin, usually promptly, with 
retention, which if not looked for by the surgeon may pass unnoticed, since 
it gives the patient no pain, until the distension of the bladder has be- 
come so great that the urine begins to dribble away through the urethra. 
This distension is of itself sufficient to cause cystitis. If the retention 
is noticed, and the catheter used regularly the appearance of the cystitis 
will be delayed ; the urine gradually becomes turbid, ammoniacal, and 
charged with mucus, and remains so until death or until improvement 
has taken place in the paralysis. After a period that is usually short, 
the retention passes into incontinence, either complete or by overflow. 
The symptoms and usual consequences of the cystitis are such as are 
commonly observed when the same affection is excited by other causes, 
and do not require a detailed description here ; but in addition to these 
common ones there are occasionally observed others of great gravity, 
such as sloughing of the wall of the bladder, and pericystitis with forma- 
tion of abscesses. In one of Gurlt's cases, there was found at the 
autopsy a sac filling the pelvis and reaching half way to the umbilicus, 
and containing nearly a pint of offensive pus and urine ; its wall was 
dark colored, and from it hung numerous soft putrid shreds, the only 
remains of the bladder. The prostate projected half an inch into this 
cavity, and the urethra was pervious. A fistulous opening above Pou- 
part's ligament led into the cavity. The ureters and pelves of the kid- 
neys were enlarged and contained purulent urine. 

In exceptional cases the bladder wall may be found hypertrophied 
and its cavity contracted. In two such cases, the patients were 3i and 
36 years old, and survived 52 and 33 days. The thickening of the wall 
was doubtless inflammatory and not a true muscular hypertrophy. 

In a few cases a very notable diminution in the quantity of urine has 
been observed, not more than three or four ounces being secreted in the 
twenty-four hours. The ammoniacal condition of the urine is due to 
fermentative changes carried on within the bladder, and not to a modi- 
fication of the urine itself as secreted. In a few cases it has remained 
unchanged in the bladder, and in others it has changed spontaneously 
from clear and acid to turbid and alkaline and back again several times. 

Every effort should be made to delay the appearance of this compli- 
cation and to diminish its severity, and with this object the water must 
be regularly drawn as soon as the first signs of retention appear. It is 
usually sufficient to use the catheter twice a day ; it must be passed 
with even more than the usual precautions and gentleness because the 
patient's insensitiveness creates an additional risk of doing damage un- 



FRACTURES OF THE VERTEBRA. 273 

wittingly to the urethral wall. After cystitis has appeared and the 
urine has become turbid, the bladder should be washed once or twice a 
day, preferably by the aid of a fountain syringe, with warm water either 
pure or containing carbolic acid, borax, or quinine, or, if decidedly 
ammoniacal, a little dilute nitric acid. 

Bed-sores appear promptly after any fracture that has caused para- 
plegia, sometimes as early as the second day. The skin at first becomes 
white, then mottled, and then separates as after blistering ; then the 
deeper part sloughs, and the slough spreads peripherally and in depth. 
The commonest seat is the skin covering the convexity of the sacrum, 
then other prominent points upon the back and legs. ISTot infrequently 
when the slough over the sacrum separates the bone underneath is 
found necrosed, and in one instance the fall of this sequestrum opened 
the vertebral canal, with a fatal result. The cause of this early slough- 
ing has been thought to lie in injury to nerves or nerve centres presid- 
ing over the nutrition of the parts ; but Mr. Shaw 1 explains it by the 
pressure which is continued for a length of time and with an absence of 
interruption unknown except in connection with paralysis. Not only is 
the patient unable to move, but he is insensitive to the prolonged pres- 
sure, and does not seek to change his position or to have it changed. 
He lies absolutely motionless in one settled position ; the pressure 
interrupts the circulation at certain points, and, if this interruption con- 
tinues unrelieved, the part dies. The presence of urine or liquid feces 
may prove an additional source of irritation, as may also creases or 
irregularities in the bed-clothing, and lack of attention and scrupulous 
cleanliness. The rapid improvement which sometimes takes place in 
these sloughs, even when the paralysis remains complete, as soon as the 
consolidation of the fracture is sufficiently advanced to allow the patient 
to be readily moved, is an additional demonstration that they are due to 
the pressure and not to the paralysis. Some cases which have recovered 
with permanent paraplegia have shown, on the other hand, a very 
marked tendency to the formation of sloughs on slight provocation. 

Bed-sores are a serious complication, for the suppuration is exhaust- 
ing, increases the difficulty of nursing the patient properly, and involves 
the risk of pyaemia. Their formation may sometimes be averted, or 
least delayed, by painting the exposed parts with flexible collodion ; 
but the best means of preventing them, or of healing them when formed, 
is the use of water beds or cushions which equalize and distribute the 
pressure. Pressure may be taken temporarily off parts which threaten 
to slough by the use of inflated rubber-rings or of several thicknesses of 
plaster placed on each side of the affected part. Great care must be 
taken to keep the sheet on which the patient lies smooth and dry, and 
to protect the perineum and buttocks from being soiled by dribbling 
urine and feces. 

In those cases in which the patients survive the injury and its more 
immediate consequences, it is sometimes found that the paralysis grad- 
ually diminishes and may even disappear entirely. The beginning of 
the improvement is marked by the appearance of sharp darting pains in 

1 Holmes's Syst. of Surg., Am. ed., vol. i. p. 810. 
18 



274 FRACTURES OF THE VERTEBRAE. 

the limbs and of muscular twitchings excited by slight causes, such as 
pinching or touching the skin ; then the power of voluntary motion 
returns, first in one muscle, then in another, usually manifested first by 
movements of the toes, for the great majority of the cases of improve- 
ment and even of survival are those in which only the lower limbs are 
paralyzed. Sensation returns usually before motion ; the bladder is 
found to be again able to retain a certain quantity of urine and to expel 
it with some force ; and a similar improvement is presented by the rec- 
tum, although, as a rule, even in the best cases, the functions of the 
rectum and bladder remain partially and permanently disabled. There 
is usually partial incontinence of both urine and feces. The improve- 
ment in the paralysis may be very slight, or it may go on to complete 
restoration of function, or it may be arrested at any intermediate stage. 
Cases have been referred to in which a permanent deformity existed, 
but the functions of the body and limbs were in no manner disturbed by 
it. Finally, in one or two cases, secondary fracture has occurred and 
caused death. 

Treatment. — While the indications for treatment are the same as in 
other fractures — to reduce the displacement and maintain. the reduction 
until repair shall have taken place — they can rarely be efficiently met, 
and are, moreover, associated with many others affecting the patient's 
life or comfort. 

When a fracture is first received it is important, and especially so if 
the fracture occupies the cervical spine, that no movement should be 
communicated to the fragments which might increase their displacement 
or create a fresh one ; the patient should therefore be handled very 
carefully, and his head and neck should be supported in case of need 
upon a large firm pillow that will immobilize them. Shaw recommends 
for this purpose a sac or pillow-case filled with sand. If there is much 
displacement, an attempt may be made to overcome or diminish it by 
cautious extension, applied either by the hands or by a weight and 
pulley, and aided by cushions or pads placed so as to make lateral 
pressure (coaptation), and frequently shifted so as to avoid sloughing. 
The gypsum-jacket has been recently employed to support the trunk 
during repair, and some interesting and successful cases have been re- 
ported. Kiister, 1 of Berlin, reported four cases at the Congress of the 
German Surgical Association, in three of which much benefit had resulted. 
In all, suspension was made under chloroform, and the angle forcibly 
straightened by pressing it forward until the bone was felt to yield with 
a snap ; then permanent extension (22 pounds) was applied to the 
head. This was followed by gradual improvement of the paralysis, and 
was repeated tw T ice. The discussion that followed brought to light the 
fact that the method had been employed not infrequently (as early as 
1862 by von Langenbeck) and with a fair measure of success, but most 
of the surgeons thought its use should be restricted to the less severe 
cases. Berkeley Hill 2 has recently reported a successful instance of 
its use after fracture in the lower dorsal region, and Drs. Hodgen and 

1 Supplement Centralblatt fur Chirurgie, 1881, No. 20, p. 33. 

2 Med. Times and Gazette, 1881, vol. i. p. 388. 



FRACTURES OF THE VERTEBRA. 275 

Ashhurst have used it to give support to the trunk so that the patient 
could be placed in a chair during the day. I have tried it twice in 
cases of fracture in the lower dorsal region in adults, but Avithout bene- 
fit. In making extension by suspension the patient must be carefully 
watched and the traction increased very cautiously ; in one case I found 
it necessary to make very limited extension by placing the patient upon 
a plank and raising him from the horizontal to the inclined position, the 
shoulders being fixed to the upper end of the plank, and the weight of 
the lower limbs making the extension. Instead of making the jacket in 
the usual manner by many turns of a roller-bandage, it is better to take 
eight or ten thicknesses of gauze of suitable size and shape, soak them 
in plaster- cream, pass them under the trunk as the patient lies upon the 
plank, and then fold them around so as to overlap in front while exten- 
sion is maintained. 

Strychnine and ergot, the latter in large and increasing doses, are 
thought to aid improvement ; and electrical stimulation of the muscles 
may be profitably employed to prevent their degeneration, while the 
restoration of the functions of the nerves is waited for. Bloodletting 
and surface irritation are to be avoided. 

Operative interference, other than that of extension to overcome dis- 
placement, has been limited to the removal of splinters after gunshot 
fracture and to the removal of the spinous processes and adjoining por- 
tions of the arches of one or more vertebrae to relieve pressure upon the 
cord. So far as is known the first operation of either kind was by Louis 
in 1762 ; an officer had received a shot in the back which caused para- 
lysis of the lower limbs and retention of urine. Louis enlarged the 
wound on the fourth or fifth day, and removed the ball and several loose 
splinters.; the patient recovered, but his legs remained weak and small. 
Twenty-four similar cases are reported in the Medical and Surgical His- 
tory of the War of the Rebellion (Part First, Surgical Volume, pp. 455 
and 459), of which only ten died. In nine of the successful cases " the 
spinous process alone or portions of it only were removed, and that the 
injuries to the vertebral column could not have been of a very serious 
nature is shown by seven of the patients having been speedily returned 
to duty or exchanged." " In the five cases of recovery in which por- 
tions of the laminae or of the transverse processes were removed, the 
results were much less satisfactory, and nearly all of the patients still 
suffer from serious disabilities." 

The conversion of a simple into a compound fracture by incision, in 
order to remove fragments that press upon the cord or to replace dis- 
placed vertebrse, is mentioned in the writings of some of the older sur- 
geons, as far back even as Paulus iEgineta, and is spoken of by some as 
if it had been actually performed ; but the first positively known instance 
is the one in which Cline, 1 in 1814, performed the operation after frac- 
ture of the seventh, eighth, and ninth cervical vertebrae, the spinous pro- 
cesses and adjoining portions of the arches being forced in upon the cord. 
Dr. Ashhurst 2 has collected forty more or less well-authenticated cases, of 

1 New England Journal of Med. and Surg., January, 1815.. 

2 Princ. and Pract. of Surgery, 2d ed. 1878, p. 336.. 



276 FRACTURES OF THE VERTEBRAE. 

■which only three were said to have been relieved. The propriety of the 
operation has been discussed with much warmth upon both sides, especi- 
ally between Sir Astley Cooper and Sir Charles Bell in the early part 
of this century. Of late years its chief advocates have been Brown- 
Sequard, Nunneley, and Felizet, while the authors of most of the syste- 
matic treatises upon Surgery or Fractures have withheld their approval. 
While I believe that the danger of the operation has been considerably 
overstated by its opponents, and that it might be still further diminished 
by the use of the antiseptic method, still, as in many cases the necessary 
change in the position of the parts cannot be effected, because the pres- 
sure upon the cord which it is desired to relieve is made in front by the 
inaccessible body of the vertebra, and as the diagnosis must always 
remain somewhat uncertain and incomplete, I do not believe that sur- 
geons will feel justified in undertaking it except under rare circum- 
stances, such as fracture in the cervical region with a fair probability of 
finding that the pressure upon the cord is due to a displaced spinous pro- 
cess. In the dorsal and lumbar regions the fracture, even when due to 
direct violence, usually involves the body of the vertebra, and if pressure 
is made upon the cord in consequence it is made in front and not behind, 
and its seat is outside the field of a prudent operation. It is certain 
that better results have been obtained by suspension and the plaster 
jacket than by trephining, and if the promise held out by the few cases 
in which the former method has been tried should be confirmed by fur- 
ther experience there would seem to be no reason to have recourse to 
the other. 

The operation has usually consisted in a long incision in the median 
line, through which the spinous processes and arches were exposed ; the 
latter were then cut through with saws, trephines, or forceps, and the 
spinous process lifted out. It has been proposed to accomplish the 
same result by passing a stout hook through the skin, engaging it in- or 
under the depressed portion, and then drawing upon it until the displace- 
ment is overcome, but I am not aware that the attempt has ever been 
made. 



FRACTURES OF THE NOSE. 277 



CHAPTER XIV. 

FRACTURES OF THE BONES OF THE FACE. 

1. Fractures of the Nose. 

Under this term we include not only the two nasal bones, but also 
those upon which they rest, the septum, the nasal process of the supe- 
rior maxillary, and the nasal spine of the frontal. The fracture may 
involve one or both nasal bones or adjoining processes ; it may be simple 
or compound, multiple or comminuted ; and it may be associated with other 
fractures of neighboring bones, the most important of which is fracture 
of the cribriform plate of the ethmoid. In the great majority of cases 
the fracture is a more or less comminuted one, occupying the lower half 
of the nasal bones, the main line of fracture running transversely or 
obliquely, and the fragments are displaced backwards or backwards 
and to one side, according to the direction of the force that has pro- 
duced the injury. In rare cases the fracture involves only one nasal 
bone, with or without displacement of the lower fragment, or there 
may be dislocation of one or both bones. Gurlt collected three cases 
of this dislocation or diastasis, two of one bone, and one of both bones. 
The cases in which the blow has fallen upon the upper portion of the 
nasal bones and has fractured the cribriform plate of the ethmoid or 
the nasal spine and adjoining parts of the frontal are rare, and belong 
among fractures of the skull rather than among fractures of the nose. 
The perpendicular plate of the ethmoid is so slight and so flexible that 
it will itself break or bend before it can transmit a fracturing force to 
the cribriform plate. The cartilages which form the alae may be broken 
or torn from their attachments to the bone, and that which forms the 
lower part of the septum is frequently broken in connection with frac- 
tures of the bones themselves. 

Dr. Hamilton 1 says that of the twenty-five cases mentioned in his book 
only fourteen were seen by a surgeon in time to receive treatment, and 
he urges therefore that the possibility of this injury should always be 
borne in mind, and that search should be made for it whenever there is 
reason to suppose that it may be present. The symptoms by which it 
may be recognized are deformity, mobility, and crepitus. The swelling 
of the soft parts, which appears promptly and is usually sufficient to 
completely mask the outline of the parts, may make the diagnosis diffi- 
cult, and the sensitiveness of the mucous surface of the nostrils is such 
that any exploration from that side meets with many objections and 
perhaps the positive refusal of the patient to allow it. Still, unless the 
swelling is very great and the displacement very slight the deformity 

1 Loc. cit. , p. 101. 



278 FRACTURES OF THE BONES OF THE FACE. 

will be recognized ; and indeed the ease with which it is recognized in- 
creases the desirability of reducing it, for any irregularity in a member so 
prominent as the nose is certain to attract attention, and may become the 
source of much annoyance to the unfortunate patient. ' 

Other symptoms which may be present but which are by no means 
pathognomonic, are free bleeding from the nose, and occasionally em- 
physema of the eyelids and face. Bleeding is often severe and some- 
times recurrent and difficult to arrest, but rarely endangers life. Em- 
physema generally has its origin in an eifort of the patient to blow his 
nose ; the air is forced into the subcutaneous cellular tissue through a 
rent in the mucous membrane and periosteum and spreads promptly to 
the eyelids and sometimes over the rest of the face. 

It is so important that a fracture should be recognized and its dis- 
placement corrected, that an anaesthetic should be used if a thorough 
exploration cannot be made without its aid, and the surgeon should spare 
no pains to satisfy himself as. to the condition and position of the bones. 
The examination cannot prudently be postponed, for the bones of the 
face unite promptly, and more than once it has been found impossible to 
correct a displacement after eight or ten days had elapsed ; firm union 
may be expected within a fortnight or three weeks. 

An occasional symptom, when the fracture has extended into the 
adjoining portion of the superior maxillary bone, is obstruction to the 
flow through the lachrymal duct in consequence of its inclusion in the 
line of fracture. Another and more common one is the difficulty or im- 
possibility of breathing through the nose, the result of inflammatory 
swelling of the mucous membrane : and, finally, in the comminuted frac- 
tures that are or have become compound, suppuration may be maintained 
for weeks or months until all the necrosed fragments have worked their 
way out or have been removed. It occasionally happens, too, that after 
a simple fracture a tendency is manifested towards inflammatory compli- 
cations in the neighborhood, abscesses form in and about the nose, por- 
tions of bone or cartilage become necrosed and are exfoliated, and a 
constant purulent discharge from the nostrils is maintained by carious 
bone or persistent ulcers, 

The prognosis as regards life is favorable, except in those cases in 
which the skull is at the same time broken, and in those few others in 
which recurrent hemorrhages, of which no satisfactory explanation is 
given, show themselves. But as regards the avoidance of deformity the 
outlook is not so favorable, because it is not always easy to recognize or 
correct a displacement through the swollen tissues, and the persistence 
of even a slight one is likely to be a very noticeable blemish. In those 
cases in which there has been loss of substance or in which the nasal 
bones remain depressed to the level of the superior maxillary bones the 
deformity is extreme. 

The treatment consists mainly in the reduction of the displacement, 
for it is seldom possible to apply any apparatus or dressing that will 
prevent a recurrence of the displacement if there is any tendency towards 
it. The reduction is accomplished by pressure made from within the 
nostril, aided by manipulation or modelling of the fragments on the out- 
side. The interval between the septum and the side of the nose at the 



FRACTURES OF THE NOSE. 279 

part of the nostril corresponding to the nasal bone is small, so small that 
it will not ordinarily admit an instrument as large as a female catheter, 
and therefore it is useless to attempt reduction by passing the finger into 
the nostril ; a small strong instrument, such as a steel director, must be 
used, one that is small enough to work within the narrow space next the 
nasal bone, and strong enough to transmit considerable pressure. The 
fingers of the left hand placed upon the nose serve to guide the instru- 
ment and to recognize the degree of reduction that has been obtained. 
Ordinarily there is but little tendency to recurrence of the displacement, 
except when the fracture is comminuted and the septum badly broken ; 
the only forces that tend to change the position of the fragments are the 
swelling of the external soft parts, and the pressure of the air when the 
patient seeks to clear his nose by snuffling or blowing. The older sur- 
geons attached much importance to dressings of adhesive plaster cover- 
ing the nose and designed apparently to keep the bones in place by 
holding up the skin. It does not appear that they serve any other pur- 
pose than that of protecting the parts from further violence. 

The idea of supporting the fragments by pressure from within the 
nostrils suggests itself so readily that it is not surprising to find recorded 
many instances and several varieties in the methods of its use. The 
simpler ones consist of plugs of lint crowded into the nostrils, with or 
without tubes to permit breathing ; the more elaborate ones are arrange- 
ments of rods supported by straps crossing the upper lip, and capable 
of adjustment in length and direction within the nostril so as to hold the 
fragments in place ; they are said to have been efficient in some difficult 
cases. On the other hand, I can find no evidence that the plugs of lint 
serve any useful purpose. I have had no experience with them, but I 
should imagine their adjustment to be difficult, their fixity uncertain, 
and their presence the cause of much discomfort. Instead of trying to 
prevent displacement by such means I should confine my efforts to over- 
coming the displacement once or twice a day, so long as it recurred, 
trusting to the rapidity of repair to soon render such interference un- 
necessary. 

Dr. L. D. Mason 1 recommends a method by which good results have 
been obtained in four cases of extensive fracture. He transfixes the 
nose, after reduction, just below the fragments with a stout needle and 
steadies the pieces with a strip of rubber or adhesive plaster crossing 
the bridge and caught upon the ends of the needle. The needle is left 
in place for about ten days. 

Emphysema needs no special treatment ; it tends to disappear promptly 
and spontaneously by absorption. Swelling may be such as to require 
the use of cold applications or of leeches, and bleeding may be so severe 
as to require plugging of the nostrils. The patient should be cautioned 
against making any forcible inspiratory or expiratory acts, especially 
snuffling and hawking, lest he should displace the fragments or occasion 
a fresh hemorrhage or emphysema. 

For the details of the methods by which deformity due to a badly 
united fracture may be relieved, the reader is referred to works upon 

1 Annals of the Anat. and Surg. Soc, Brooklyn, vol. ii. p. 107, and vol. iii. p. 81. 



280 FRACTURES OF THE BONES OF THE FACE. 

reparative and operative surgery. In some cases it is sufficient to sepa- 
rate the cartilages of the alse from the nasal i>ones by a subcutaneous 
incision and to divide the septum ; in others the displaced bones and the 
septum need to be broken with stout forceps, and in on£ case in which 
this plan failed, Dr. R. F. Weir obtained an excellent result by cutting 
down upon the side of the nose, dividing the bone with a chisel, and 
maintaining it in the desired position for a few days by a rod attached 
to a band about the head. 



2. Fractures of the Malar Bone and Zygoma. 

Isolated fractures of this bone are rare, and, so far as can be inferred 
from the small number of cases in which a direct examination has been 
possible, single fractures are rarer than multiple ones, and the rarest is 
that which is almost a simple diastasis, a separation at the sutures with 
some splintering. Partial fractures involving the lower and outer portion 
of the bone or the margin of the orbit have been observed, and also 
single fractures of the frontal and zygomatic processes, extending possibly 
into the bones with which they articulate. In most cases there is de- 
pression of the entire bone with fracture of the malar process of the 
superior maxilla and crushing of the anterior wall of the antrum, the 
malar bone being displaced inwards towards the antrum or sometimes 
backward into the zygomatic fossa. Pure diastasis of the malar bono 
probably does not exist; it has never been demonstrated by autopsy, and 
attempts to produce it upon the cadaver have always resulted in more 
or less fracturing. Gurlt has collected three cases described as diasta- 
sis, in which the lines of separation apparently followed those of the 
sutures very closely. The principal peculiarity in these cases is in the 
displacement, which instead of being inward towards the antrum, as is most 
common after fracture, was downward and outward in one, and upward 
and inward towards the orbit in another ; and in the third, in which the 
zygoma was not broken or separated, the frontal process of the malar 
bone was displaced forward and a little inward, and there was a depres- 
sion in the lower margin of the orbit at the junction of the malar and 
superior maxillary bones. 

Fractures of the zygomatic arch alone have been caused by external 
violence acting from without inwards, as a fall, a blow of the fist or a 
ball, and in two cases from within outwards, the patient having fallen 
forward upon a stick held in the mouth. Hamilton's experiments upon 
the cadaver indicate that the fracture usually takes place in the tempo- 
ral portion of the zygoma, a little behind the suture. The displacement 
follows the direction of the fracturing force. 

The symptoms upon which the diagnosis must be made are deformity, 
mobility, and crepitation. Unless there is much inflammatory swelling 
or extravasated blood, the deformity, which consists usually in a depres- 
sion or flattening of the cheek just below the outer half of the eye, can 
be recognized by sight and touch, and the irregularity of the line of 
fracture can be readily felt on the margin of the orbit, or, if it extends 
to the malar process of the superior maxillary bone, on the under and 
anterior surface of this process by the finger within the mouth. Mobility 



FRACTURES OF THE MALAR BONE AND ZYGOMA. 281 

and crepitation are perceived more rarely ; the latter can be sometimes 
produced by the movement of the jaw. 

Anaesthesia or a sense of formication in the cheek, nose, upper lip, 
and gum of the corresponding side is sometimes observed, and is due 
to an extension of the fracture along the floor of the orbit, involving 
the infra-orbital canal and tearing or bruising the superior maxillary 
nerve. This symptom may be associated with an extravasation of blood 
in the posterior part of the orbit sufficient to force the eye forwards and 
showing itself also under the conjunctiva and in the eyelids. Bleeding 
from the mouth or nose is occasionally seen as the result of the exten- 
sion of the fracture through the mucous membrane of the mouth or 
antrum. 

When the fracture involves the zygomatic arch, and the fragments, as 
is usually the case, are driven inwards, movement of the jaw may be 
difficult or impossible, either because the masseter has been injured, or 
because the depressed fragments of the arch are forced against the eoro- 
noid process of the inferior maxilla, or into the tendon of the temporal 
muscle. In one case the tip of the coronoid process was broken off by 
the same blow that fractured the arch. Swelling, discoloration, and 
pain are the natural and constant results of the fracture and the bruising 
of the soft parts. 

The natural course of these fractures is towards rapid repair without 
excessive callus, and with gradual disappearance of any difficulty that 
may exist at first in the movements of the jaws. It is seldom possible 
to reduce the displacement completely, because, as has been said, it is 
generally inwards and there is no way of acting very efficiently upon 
the bone, except through a wound of the skin. The attempt must be 
made to move the bone in the desired direction by engaging the end of 
the thumb or finger under it in the zygomatic fossa, introducing it through 
the mouth if the cheek is swollen. It has been proposed, and occasion- 
ally practised, to cut down upon the bone opposite the zygomatic pro- 
cess, divide the fascia overlying the masseter muscle, pass a stout hook 
under the process, and raise the bone by drawing upon it, or to make a 
smaller incision over the body of the bone and screw an elevator into it, 
by which it could then be raised. If the incision is so made as not to 
transform a simple into a compound fracture there can be no serious ob- 
jection to the plan whenever the displacement is sufficient to cause much 
disfigurement, and there is even less reason to refuse to use the existing 
wound of a compound fracture for the same purpose. 

Inward displacement of the zygomatic arch cannot be directly acted 
upon except through the skin. Ferrier raised the bone in a simple frac- 
ture, and Dupuytren in a compound fracture, in this manner. Consider- 
able suppuration followed in the latter case, but the patient made a good 
recovery. In only one of the recorded cases has the displacement inter- 
fered seriously and for any length of time with the movement of the 
jaw T s ; in this one the difficulty increased steadily for some time until the 
patient could barely separate the teeth, and then one morning while 
yawning he felt something snap, and the motion of the jaw at once be- 
came and remained free. 

Outward displacement of the same portion of the bone can be readily 



282 FRACTURES OF THE BONES OF THE FACE. 

corrected by pressure, and that of the body of the bone can usually be 
corrected almost entirely by the same means. No dressings are needed 
other than those designed to favor the repair of the bruised soft parts. 

3. Fractures of the Superior Maxilla. 

While the body of this bone, protected as it is by outlying processes 
and other bones, is rarely fractured, its own processes are not infrequently 
broken or involved in the fractures of those bones with which they are 
continuous. Thus, a blow upon the nose breaks not only the nasal bones 
but also the nasal process of the superior maxilla, and a blow upon the 
malar bone may force in the anterior wall of the antrum on which it 
rests. The fractures are always produced by direct violence, and present, 
consequently, considerable variety in their extent and the parts involved. 
The alveolar process may be broken off in part or entirely by a blow 
received on it or on the teeth. A blow received in front, at or below 
the level of the nostrils, may produce a horizontal line of fracture sepa- 
rating the alveolar and palatal processes from the body of the bone, and 
including also the pterygoid plates. Falls from a height have caused a 
vertical line of fracture or diastasis between the two bones along the 
median line of the mouth, extending even through the soft palate and 
associated with fracture of the malar or nasal bones. Fractures of the 
roof of the mouth are usually multiple, and the most severe ones appear 
to be those caused by a blow received upon the malar bone which has 
crushed in the wall of the antrum. In a case of this kind mentioned by 
Hamilton, an attempt to remove a loose molar tooth u brought down 
several teeth and the whole floor of the antrum," attached to which was 
found, after its removal, a considerable portion of the pyramidal process 
of the os palati. Fractures of the alveolar process, even with much dis- 
placement and mobility, present but little gravity, for they heal rapidly 
and without necrosis. 

It occasionally happens that one or both bones are driven in with 
multiple and comminuted fracturing of them and of the adjoining ones. 
The earliest known case of the kind was reported by Wiseman, and has 
been extensively quoted. The upper jaw was driven in so far that the 
finger could not be introduced between the palate and the posterior wall 
of the pharynx. Wiseman inserted a blunt hook through the mouth and 
easily drew the bone forward into place; as, however, the displacement 
recurred very easily he left the hook behind the palate and had it drawn 
upon constantly by the patient or his friends until consolidation had 
taken place. Quite a number of similar cases (Gurlt has collected up- 
wards of twenty) have been reported, all the result of great violence, 
either by falls from a height or the passage across the face of a heavy 
wagon, or a violent blow. In one case the bones of the face were so 
movable that they moved up and down when the patient swallowed, as if 
they were restrained only by the skin. In most of them the patients 
recovered, and it is worthy of remark, that notwithstanding the degree 
of the violence and the extent of the injury, it seldom happens that the 
fracture involves the skull. The reason lies apparently in the direction 
in which the fracturing force is applied, a direction outside of, and more 
or less parallel to the surface of the skull, and not in the line of one of its 



FRACTURES OF THE SUPERIOR MAXILLA. ^80 

diameters. The bones of the face are, as it were, torn off the skull 
rather than driven back upon it. 

Very extensive mutilation of the face has been caused by gunshot 
wounds, especially in attempts at suicide when the muzzle of the gun 
has been placed within the mouth, but it is rare for ordinary violence to 
lead to much loss of tissue. Malgaigne speaks of the following case as 
unique in this respect in his experience. A lad was kicked in the face by 
a horse ; the superior maxillary, nasal, and palatal bones were extensively 
comminuted, and the skin torn and bruised. Recovery took place, but 
with much deformity. The nasal bones, the anterior portion of the alve- 
olar arch, and the greater part, if not all, of the hard palate had disap- 
peared. There was no longer either nose or mouth ; the lips were 
united by a firm cicatrix, and the mouth and nostrils were represented 
by an oval opening between the nasal processes of the superior maxillae. 
Through this opening the patient breathed, spoke, drank, and ate. 
< The diagnosis of fracture is ordinarily made without any difficulty, 
since large portions of the bone are open to direct examination with the 
finger through the mouth and on the cheek. Irregularity of outline, 
mobility, displacements, and crepitation can be readily recognized. In 
some few cases where there was no displacement the diagnosis has been 
in doubt, and Gue'rin 1 has pointed out a symptom which might be useful 
under such circumstances. It has been said that the pterygoid apophysis 
is always broken when the line of fracture crosses the jaw horizontally 
between the alveolar process and the malar bone, and Guerin found that 
pressure with the finger upon the inner plate of this process caused pain 
and sometimes showed mobility when there was no other sign of fracture. 
It is, however, extremely difficult to recognize the extent of the fracture in 
those comparatively rare cases in which the bones of the base of the skull 
are likewise broken, because they are removed from the range of direct 
examination. As a rule, the diagnosis can be completed only after the 
lapse of the period of time which is necessary to the appearance of the 
grave symptoms to which such extension of the fracture may give rise. 

Repair in cases of average severity takes place in from thirty to forty 
days with a scanty formation of callus, and not infrequently in less time. 
The vitality of the bone is exceptionally great, hence the rule laid down 
by Malgaigne and some of his predecessors, and repeated by all subse- 
quent writers, to leave every fragment that is not absolutely and entirely 
detached. Although the rule is a sound one, it occasionally happens that 
fragments become necrosed, and have to be removed. This is thought 
to happen more frequently with fragments of the alveolar border than 
with any others. 

Displacement is seldom noticeable after repair is completed, except in 
the nose, but it usually exists to a greater or less degree, and the inge- 
nuity and the patience of the surgeon are often severely taxed to over- 
come the constant tendency to the recurrence of the displacement. Sali- 
vation is often profuse, and the discharge offensive. Division of the 
lachrymal canal by the fracture may lead to its obliteration. 

Displacement of the entire bone may be treated as in Wiseman's case, 
or the retention may be aided by securing the lower jaw against the 

1 Archives Generates de Medecine, July, 1866, vol. ii. p. 5. 



284 



FRACTURES OF THE BOXES OF THE FACE 



Fig. 142. 



upper one, ivith or without the intervention of interdental splints or 
moulds of gutta percha, or metal shaped to fit the teeth and alveolar 
arch. Lateral pressure cannot well be made upon the cheeks to over- 
come separation along the median line of the palate, but fortunately it is 
not always necessary. In Simonin's case, quoted by Malgaigne, the gap 
began to contract spontaneously by the tenth day, and was completely 
closed by the thirty-third, with no other displacement than a slight dif- 
ference in level between the two halves. In another case, quoted by 
Hamilton, the gap was large enough to admit the little finger, and was 
still open six weeks after the receipt of the injury. 

After fracture of the alveolar process the fragment should be carefully 
readjusted and fixed by wiring the teeth to the adjoining ones, or by a 
mould of gutta percha or metal. Agnew says he has used for this pur- 
pose with great advantage a piece of cork with 
grooves cut in its upper and low T er surfaces to re 
ceive the teeth of both jaws. The reduction is 
made, the cork inserted, and the jaws firmly bound 
together. No attempt should be made to remove 
the corresponding teeth, for not only are the chances 
in favor of their becoming firm again in their sockets, 
but the attempt to draw them, even if they are loose, 
may materially increase the mischief done by the 
fracture, as in Hamilton's case quoted above, in 
which such an attempt caused the loss of the entire 
floor of the antrum. 

The gutta percha or metal moulds may be held in 
place by binding the lower jaw against it after it 
has been fitted to the upper one, or by an apparatus 
similar to one devised by Graefe for the purpose, and shown in figure 
142. If the splint is to be supported by the lower jaw it should be so 
constructed that an interval will be left through which food can be given 
and the mouth cleaned. 

4. Fractures of the Inferior Maxilla. 




Intra-buccal spliut for 
fracture of the upper 
jaw. 



Fracture of the inferior maxilla occurs more frequently than that of 
any other of the bones of the face. It is rare in childhood and old age, 
most frequent between the ages of 20 and 30, and is apparently more 
than ten times as common in males as in females. 

Gurlt collected 143 published cases in which the character and position 
of the fracture were described with sufficient accuracy to allow of their 
use as statistics ; of these 80 were single, 49 double, and in 14 there 
were three or more lines of fracture. Of 75 single ones (excluding 5 
in which the fracture was limited to the alveolar process) the fracture 
occupied the median line in 25, the region of the incisor teeth in 22, 
that of the back teeth in 15, behind the teeth in 8, and the condyloid 
process in 5. In 35 double fractures both halves of the bone were broken 
20 times, and at points on the two halves corresponding closely with 
each other ; one side alone 8 times, and the median line by one of the 
fractures 7 times. One or both of the condyloid processes were broken 
in several of the multiple fractures. These figures show that, exclusive 



FRACTURES OF THE INFERIOR MAXILLA. 285 

of partial fractures of the alveolar border, which are very common, and 
often caused by the drawing of a tooth, the most frequent seat of fracture 
is at or near the median line, and that single fracture of the ramus, or 
of the alveolar or condyloid process is comparatively rare. They differ 
materially from the estimates made by various writers, but as the latter 
differ quite as much among themselves, and appear to have spoken in 
most cases from general impressions rather than from figures, the prefer- 
ence should be given, I think, to Gurlt. 

Double fractures of the lower jaw are relatively more common than 
those of other bones, while multiple and comminuted ones are rare. 
Compound fractures are common, both because the gum overlying the 
fracture is frequently torn, and because the lip and skin are often in- 
volved in the direct injury that has caused the fracture. The fracture 
is complete or incomplete, the latter rarely except when the alveolar 
border alone is involved. Cases are reported in which a portion of the 
body of the bone adjoining the alveolar border has been broken off; and 
at least one case (Hamilton) which appears to have been an infraction 
in the line of the outer incisor tooth. 

The line of fracture in the body of the bone is usually vertical or 
nearly vertical ; at the angle or in the ramus it is oblique or transverse. 
At the median line there is but little displacement, if any ; but, when 
present, it may be in either of three directions : a difference in the 
horizontal level of the edge of the teeth, a displacement forwards and 
backwards of the fragments upon each other with lateral overriding, or 
a lateral separation of the two. In the fractures between the median 
line and the canine tooth the line is still much more frequently vertical 
than oblique ; but displacement is the rule,' although no one form of it 
seems to be more common than the others. Between the canine tooth 
and the angle of the jaw it is either vertical or inclined backwards and 
downwards, and usually, instead of crossing the bone from without 
inwards at a right angle to the surface, it is inclined backwards and 
inwards, so that the anterior fragment is lengthened on the inner side 
and the posterior fragment on the outer side. The inferior dental nerve 
is crossed by this fracture, as it lies within the bone, and is sometimes 
torn or bruised. 

Fracture behind the teeth is comparatively rare, only eighteen cases 
being contained in Gurlt's statistics, and it is frequently double or 
multiple or associated with other fractures. 
When the fracture lies at the j unction of the 
body of the jaw and the ascending ramus, it is 
usually oblique, running from behind the last 
tooth backwards and outwards towards the 
angle of the jaw ; but it may be vertical. 
Displacement is usually slight or lacking, the 
parts being kept well together by the masseter 
and internal pterygoid muscles. 

Fracture of the condyloid process is usually 
accompanied by other fractures of the same or 
other bones of the face, and may be produced 
by a blow either upon the chin or upon the 

•j /» ,1 • , . . rni i ,. „ Fracture of lower jaw behind 

side ot the jaw near the joint. The line of the teet h. 




286 FRACTURES OF THE BONES OF THE FACE. 

fracture passes through the neck, and the few specimens furnished by 
autopsies and museums do not show a greater frequency at any point 
or in any direction than at any other. 

Dr. Will 1 reported a case with specimen, the patient Jiaving died in 
consequence of an associated fracture of the pelvis. The line of fracture 
was oblique backward and downward from the bottom of the sigmoid 
fossa. The symptoms were few, but the nature of the injury was quite 
evident. There was slight deviation of the chin towards the affected 
side, abnormal lateral mobility, and indistinct crepitus. Examination 
by the mouth revealed displacement of the condyle upward and forward 
by the action of the external pterygoid muscle. Dr. Will adds that, 
according to Heath, there are only six examples of this fracture in the 
London museums. Cases have been mentioned by Soranus, Desault, 
Kibes, Berard, Houzelot, Bichat, Packard, Watson (of N. Y.), and an 
incomplete one of both condyles by Verneuil. 

Fracture of the coronoid process is exceedingly rare. Gurlt's collec- 
tion contains two cases and a reference to a third. In one, both coro- 
noid processes, both condyles, and the symphysis were broken by a fall 
from a height ; in the second, 2 the coronoid process and the condyle 
were broken by a fall from a loft. The patient died of delirium tremens. 
In the third case, the zygoma and malar bone had been driven in upon 
and had broken off the tip of the coronoid process. There was exten- 
sive fracturing of the bones of the face and of the base of the skull. 

A portion of the alveolar process with the teeth in place is sometimes 
broken off. The size of the piece varies within wide limits, and the dis- 
placement is habitually inwards. In one or two entirely exceptional 
cases a similar piece, including a portion of the body of the bone, has 
been broken off. 

In double fractures, the intermediate piece is almost invariably drawn 
downwards and backwards by the unopposed action of the muscles of the 
neck which are attached to it. 

Comminuted fractures, except as the result of gunshot wounds, are 
comparatively rare ; double and treble fractures are less so ; and one 
case is on record in which there were five distinct and separate lines of 
fracture. 

In three of Gurlt's cases the autopsy showed rupture or crushing of 
the inferior dental nerve, and in two the external ear was injured, by 
fracture of its bony wall in one case, and by rupture of its cartilaginous 
portion in the other. 

The most frequent cause of fracture, exclusive of partial fractures 
produced by attempts to draw a tooth, is violence received upon the 
chin ; fracture by pressure upon the sides is much less common, the 
other occurring thrice as frequently. Hamilton mentions a case in 
which a double fracture was produced in a young woman by the grasp 
of her husband's hand. Fracture of the condyloid process may be pro- 
duced in either of the same two ways — a blow upon the chin or upon 
the cheek. Examples of fracture of the coronoid process are too rare, 
and too little is known concerning them to explain their mode of pro- 

1 Lancet, 1882, vol. i. p. 100. 2 Lancet, 1860, vol. ii. p. 536. 



FRACTURES OF THE INFERIOR MAXILLA. 287 

duction. The position of the bone is so sheltered that it can hardly be 
broken by direct violence except after fracture of the zygoma, and, 
although its fracture by the contraction of the temporal muscles has 
been alleged, there are no facts to demonstrate it. 

The objective symptoms of fracture of the lower jaw are the same as 
those of other fractures : abnormal mobility, crepitation, displacement. 
The bone is so accessible to the touch both within and without the mouth 
that irregularities in the outline of its body can be easily recognized by 
the fingers and sometimes by sight. The teeth show differences in 
level, vertically or antero^posteriorly ; those which adjoin the fracture 
are usually loosened and may be entirely displaced ; in one or two 
cases a tooth has slipped or been driven in and lodged between the 
fragments. Mobility and crepitation are detected by manipulation. 
When the fracture is situated at or above the angle of the jaw its recog- 
nition is by no means so easy ; by passing the finger within the mouth 
along the inner and outer surfaces of the ramus, irregularities of outline 
and localized points of pain may be recognized. 

The degree and direction of the displacement vary much. As a rule, 
when the fracture is single and not in the median line, the anterior frag- 
ment tends towards the inside of the mouth, and this displacement is 
favored by the obliquity of the line of fracture which, as above men- 
tioned, usually leaves the anterior fragment longer on the inside than on 
the outside. The causes of the displacement have been the subject of 
some discussion. It has been shown, on the one hand, that the usual 
displacement is produced on the cadaver by the simple action of the 
fracturing force ; and, on the other, by the recurrence of the displace- 
ment after correction, that the action of the muscles is also able to pro- 
duce it. The differences that have been noted by various observers 
corresponding to different positions of the fracture have not proved con- 
stant, and as their causes appear to have been incidental and varying, 
they do not require examination. 

In a case observed by Pierson, 1 a double fracture was occasioned by 
the passage of a wheel across the jaw, and the intermediate portion of 
bone, with the tongue, dropped back into the mouth and throat so as to 
nearly cause suffocation. The patient contrived to draw the tongue 
forward with a spoon and prevent suffocation until the surgeon secured 
the fragment by wiring the teeth. Similar consequences have followed 
resection of the median portion of the jaw. 

Pain on pressure and on movements of the jaw is a constant and well- 
marked symptom, and may be produced also by deglutition. It may 
be extremely severe, and may give rise to nervous and tetanic symptoms 
of much importance when it is due to injury of the inferior dental nerve 
within its canal. Usually injury to this nerve is shown only by anaes- 
thesia of the lower lip and chin on the affected side, usually temporary, 
but occasionally permanent. Malgaigne denies the frequency of such 
injury to the nerve, and says that he has never personally met with an 
instance of it. 

1 American Jonrn. Med. Sciences, 1841, p. 186. 



288 FRACTURES OF THE BONES OF THE FACE. 

There are no recorded clinical facts indicating the symptoms of frac- 
ture of the coronoid process. 

Fracture of the condyloid process was first studied by Desault and 
Bichat, and but little if anything has been added to our knowledge of 
the subject since their time. The symptoms are pain increased by 
motion, diminished mobility of the jaw, often crepitation on manipu- 
lation, irregularities in the region of the condyle, the ease with which 
the condyle can be pushed forward into the zygomatic fossa, its failure 
to share in the movements of the jaw, and its almost constant displace- 
ment upwards and forwards by the contraction of the external pterygoid. 
Ribes pointed out an additional symptom which is sometimes present, 
deviation of the chin towards the affected side. This is effected by the 
displacement of the ramus upwards and backwards on the outer side of 
the condyle and neck, and the more easily if the fracture is a double or 
multiple one. Gurlt quotes the description of a specimen of this kind 
from a work by Bonn, published in 1785. The condyle was united by 
a bony callus to the ramus just above the orifice of the dental canal. 

Swelling of the gums, face, and glands follows promptly upon the 
injury and is often increased by the* direct bruising of the soft parts 
themselves; the secretions of the mouth, increased in quantity by the 
irritation, mingle with the pus that comes from the fracture if compound 
or from the ulcers produced by the stomatitis, decompose, and cause an 
offensive odor that can scarcely be kept under control even by the most 
careful attention. Abscesses may form and open within the mouth or 
upon the sides of the jaw or the neck below it ; they are almost invariably 
associated with the presence of detached splinters or the exfoliation of 
portions of the jaw which require, of course, to be removed before a 
permanent cure can be obtained. Small fragments may long escape 
recognition, and the only indication of their presence may be a fistula ; 
larger fragments force themselves promptly upon the surgeon's attention 
by the profuseness of the discharge and the amount of local irritation. 
In a case reported by Ancelon, 1 of double fracture of the body of the 
lower jaw, the fracture being on one side two centimetres, and on the 
other three centimetres in front of the insertion of the masseter, the 
entire portion on each side behind the fracture became necrotic. Six 
months after the accident the left ramus was cast off spontaneously, and 
the right one was removed by the surgeon. The central piece was pre- 
served, and recovery took place with slight disfigurement. In a case 
mentioned by Desault, fracture of the neck of the condyle was followed 
by necrosis and elimination of the fragment, and in another, mentioned 
by Malgaigne, 2 Monteggia saw suppurative periostitis, total necrosis, 
and death follow fracture caused by a blow with a stick. As a rule, 
however, the vitality of fragments of the lower jaw is great, and necro- 
sis, except of limited points of the alveolar border, is uncommon. 

Simple fractures unite in from thirty to forty days, and even when 
there has been a considerable loss of bone by splintering or necrosis, 
the final result may be a very good one, in this sense, that the jaw is 

1 Gaz. des Hopitaux, 1854, p. 550. Quoted by Gurlt. 

2 Loo. cit., p. 388. 



FRACTURES OF THE INFERIOR MAXILLA. 



289 



strong enough to support artificial teeth in the place of those that have 
been lost by the accident, is sufficiently regular in form to avoid de- 
formity, and is free in its movements. 

Failure of union, pseudarthrosis, is rare. Gurlt's statistics contain 
only two cases which can be properly considered such, and they were 
both cured by operation. It is more common after gunshot fracture 
with much loss of substance by elimination of splinters, and may inter- 
fere with mastication. In a few cases union in a faulty position has 
required an operation to correct the deformity or relieve the functional 
disability. 

The prognosis is a relatively favorable one ; the probabilities are that 
union will take place promptly, that no serious complications will arise, 
and that no important deformity or disability will remain. Danger to 
life may come from two quarters : the proximity of the bone to the 
cranium carries with it the possibility of associated injury to the brain 
or to its case ; retention of pus in a compound fracture in communica- 
tion with the cavity of the mouth exposes to the grave danger of absorp- 
tion of the decomposed secretions and, if the displacement and laceration 
are great, to the burrowing of the decomposed pus along the deeper 
planes of the neck into the anterior mediastinum. 

Treatment. — Displacement following fracture of the body of the jaw 
can usually be readily overcome by the pressure of the thumb and 
fingers upon the teeth and the lower border of the bone; in some cases 



Fig. 144. 



Fig. 145. 





Barton's bandage for fracture of the lower jaw. Gibson's bandage for fracture of the lower jaw. 

the interlocking or wedging of the smaller pieces or of displaced teeth, 
may render the reduction impossible until after they shall have been 
removed, and in a case reported by Buck 1 to the N. Y, Pathological 
Society in which the bone was broken very obliquely, the displacement, 
which amounted to about half an inch, could not be overcome except by 
the division of the soft parts including the lip and the removal of the 
sharp end of the anterior fragment. In another case reported to Dr. 
Hamilton, by Dr. J. H. Packard, it was found necessary to divide the 



19 



Quoted by Hamilton, loc. eit., p. 132. 



290 



FRACTURES OF THE BONES OF THE FACE. 



attachments of the muscles to the lower border of the bone at the sym- 
physis to prevent recurrence of the displacement. 



Fig. 146. 



Fig. 147. 




Garretson's bandage for fracture of the lowei 
jaw. 



Hamilton's bandage for fracture of the lower 
jaw. 



Fig. 148. 



In simple cases where the tendency to displacement is slight it is 
sufficient to immobilize the lower jaw by binding it against the upper one 

with a bandage that passes under the 
chin and over the head and is pre- 
vented from slipping by another car- 
ried over and around the occiput. 
Different forms of bandages, which can 
be used also in connection with inter- 
dental splints, are represented in the 
adjoining figures (figs. 144 to 148). 

Splints are applied either to the 
front and under surface of the jaw out- 
side the mouth, or to the teeth, or the 
inner surface of the jaw, and two kinds 
are sometimes used in combination. 
Outside splints are available only in 
cases in which there is not much tend- 
ency to displacement and in which the 
lateral pressure of a simple bandage 
would cause the fragments to override 
in one direction or another. They 
may be made of leather, pasteboard, 
gutta percha, or plaster of Paris, and 
consist essentially of a cup-shaped piece embracing the chin and ex- 
tending nearly to the angle of the jaw on each side, and to the fold of 
the neck below. A simple method of making one in pasteboard or gutta 




Four-tailed bandage for fracture of 
lower jaw. 



FRACTURES OF THE INFERIOR MAXILLA. 



291 



percha, as described by Dr. Agnew, is represented in figures 149 and 
150. A piece of the material chosen, 4 or 5 inches long and 2 J inches 
wide, is divided longitudinally along its centre for one-third of its length 



Fis:. 149. 





\. 4- / 






1 




1 




2 


3 


2 





Pasteboard splint for fracture of the lower jaw. 



at each end. The halves are then bent at a right angle, the ends 2, 2, 
turned in, and the other ends, 1,1, turned up against them. The chin 



Fur. 150. 





2 \ 




/ 2 
/ 






3 


1 



The same, partly folded. 

fits in behind the part marked 3 in the figures. It may be necessary to 
cut away a portion from the opposite edge (4) to make it fit at the 
throat. 

Interdental splints are made of metal, gutta percha, or vulcanized rub- 
ber ; they are fitted to the crowns of the teeth of both fragments after 
reduction of the displacement, and are held in place either by binding 
the jaws together with an outside bandage, or by braces connecting the 
splint with a pad under the jaw (fig. 151), or by a special arrangement 
of lateral braces as in Kingsley's apparatus (fig. 152), or by fastening 
them to the teeth with wires. Some are fitted only to the broken jaw 
and are intended only to immobilize the fragments on each other ; 
others are fitted to both jaws and enable the upper one to be used as a 
splint for the lower. Those of which the one represented in figure 151 
may be considered the type, give the least firm support and often cause 
much discomfort by the pressure of the pad under the chin, especially 
if the soft parts are bruised and swollen. The upper portion of the ap- 
paratus is a grooved metal plate fashioned to the teeth as accurately as 
possible and designed to overlap the line of fracture ; the lower portion 
is a pad capable of adjustment at any desired point along the upright bar. 

Gutta-percha splints may be made either of thin strips or of thick 



292 



FRACTURES OF THE BONES OF THE FACE 



lumps or wedges, 
they are intended 

Fig. ]51. 



The former have a length of three or four inches, for 
to overlap the fracture, and a breadth sufficient to 
overlap the crowns of the teeth from gum to gum ; 
they are softened by immersion in hot water, 
moulded to the teeth, cooled as rapidly as possible, 
taken off and trimmed suitably. Then the splint 
is reapplied and the jaws bound together. If the 
tendency to displacement is slight the bandage 
may be loosened during the day to allow the in- 
troduction of liquid food, or a wedge may be kept 
between the jaws so as to create an interval to be 
used for this purpose, or advantage may be taken 
of the absence of teeth, especially from the upper 
jaw. Dr. Hamilton refers also to a method of 
fastening the splint employed successfully by Dr. 
J. S. Prout. A plate of gutta percha was moulded 
to the upper surface of the teeth on both sides of 
the fracture and secured by wires previously at- 
tached to the teeth. This method allows the 
In another case quoted by Gurlt 1 two fragments 
of the alveolar border carrying eight teeth were secured by a splint of 
sheet lead moulded to the teeth and fastened down by silver wire, the 
ends of which were brought out under the chin by means of a needle and 

tied over a roll of plaster. The wire 




Splint for fracture of the 
lower jaw. 

mouth to be opened.- 



Fiff. 152. 



in 



caused no irritation and was left 
place forty-seven days. 

Gutta-percha wedges were intro- 
duced by Dr. Hamilton to meet a 
double indication, that of fixing the 
fragments securely and of allowing 
the easy introduction of food. Two 
pieces of gutta percha of suitable 
size are softened and formed into 
wedges and introduced between the 
jaws, the edge of the wedge directed 
backward. The jaws are closed 
upon them, the fragments pressed 
up until the lower border of the jaw 
is straight, and the wedges moulded 
to the sides of the teeth above and 
below. As soon as the gutta percha 
has hardened it is removed, trimmed 
suitably, and reapplied, and the jaws 
are bound together with a bandage. 
Vulcanized rubber is a valuable 
substitute for gutta percha in some difficult cases, but its employment 
requires special skill and experience which are found usually only among 
the dentists. Casts of one or both jaws are first taken in wax ; from 




Kiugsley's splint applied. 



1 Loc. cit., vol. ii. p. 393. 



FRACTURES OF THE INFERIOR MAXILLA. 



293 



these plaster models are made, and upon these latter the splint. Figures 
152 and 153 show the splint as made by Dr. Kingsley, of New York, 



Fig. 153. 




Kingsley's interdental splint. 

with attached bars by which the splint and jaw can be bound firmly 
together, the bandage passing from one bar to the other underneath the 
chin. 

Another method, which dates back to Hippocrates (see page 187), is 
to fasten together the teeth on opposite sides of the fracture by thread 
or wire. In some cases this answers the purpose, but more frequently 
the wires break, the teeth become loose, and the jaws sore. If used, 
two or three teeth on each side of the fracture should be included in the 
loops. 

The teeth have been wired together also in other ways to prevent dis- 
placement ; thus, the lower jaw has been immobilized against the upper 
one by binding corresponding teeth together, or by fastening a back tooth 
of the lower jaw to a front tooth of the upper jaw, for example, or one 
on the left side to another on the right side. In at least one case, where 
a sufficiently firm hold could not be got by wrapping the wire about the 
teeth, the latter were perforated with a drill and the wire passed through 
the holes. 

In a few cases of compound fracture the bones themselves have been 
drilled and wired together as in operations for pseudarthrosis. 

Gurlt 1 quotes two cases in which displacement inward was overcome 
by a metal apparatus fitted to the inside of the jaw and opposing the 
displacement by a screw or a spring. In each case the fracture was on 
the side of the jaw. 

Repair takes place so rapidly that, except in compound fracture with 
much suppuration, there is rarely any tendency to displacement after 
the tenth day, and therefore the discomforts incidental to the continuous 
closure of the jaws do not need to be borne for any great length of time. 
If the importance of the case warrants it, if the displacement can be 
prevented only by keeping the jaws constantly in contact with each other, 
the patient can be fed through a tube passed behind the last molar tooth, 
or through the nose. It has been shown of late that a tube through 
which the patient can be exclusively nourished can be worn permanently 

1 Loc. cit., vol. ii. p. 439. 



294 FRACTURES OF THE BOXES OF THE FACE. 

in the nostril and oesophagus, without inconvenience, for several months. 
Krishaber has done this in one case with a gum oesophageal tube, and 
Verneuil with soft rubber catheters in several cases, for days at a time, 
after operations upon the mouth. 1 There seems to be no reason to 
doubt that the same measure could be employed successfully, in case of 
need, after fracture of the jaw. 

Cleansing and disinfecting washes containing chlorate of potash, borax, 
or alum will be found to add much to the comfort of the patient when- 
ever they can be used. 

After fracture of the neck of the condyle the tendency is to the dis- 
placement of the condyle forwards by the traction of the external ptery- 
goid muscle, and as the fragment is too small to be acted upon directly 
by any dressing this tendency, if manifested, cannot well be overcome. 
The treatment, therefore, is to reduce the displacement if it exists, and 
then to immobilize the jaw after having pressed it backward and upward 
to interlock the fragments. Ribes reduced the displacement by passing 
his forefinger into the mouth and along the inner side of the ascending 
ramus until he reached the condyle and was able to press it back into 
place. Fountain, of Iowa, obtained a good result by drawing the jaw 
well forward and wiring the teeth together, so as to maintain the position. 

Fracture of the coronoid process is not open to any treatment except 
immobilization. 

Fractures of the alveolar border are best treated, like fractures of 
the body, by immobilization after careful reduction of the displacement, 
and it is advisable not to make haste to remove loose or semi-detached 
teeth. They may become firmly adherent again, or, if this should fail, 
they may be removed subsequently without having caused any serious 
trouble or delay. 

Delayed union and pseudarthrosis are to be treated by the removal of 
the cause, if any definite local one exist, or by operative interference, 
freshening of the surfaces of fracture, and wiring of the fragments. 

i Bulletins de la Soc. de Chirurgie, 1881, pp. 220-229, 



FRACTURES OF THE HYOID BONE. 295 



CHAPTER XV. 

FRACTURES OF THE HYOID BONE.' 

This comparatively rare lesion has received the attention of writers 
only within the present century. Malgaigne collected 8 cases, Hamil- 
ton added 2, and Gibb 3 ; in 1864 Gurlt collected 27 cases, 21 being of 
the bone alone, while in 6 there was associated fracture of the thyroid 
or cricoid cartilage or of the trachea. In 3 of Malgaigne's cases and in 
5 additional of Gurlt's the fracture was caused by hanging, judicial or 
suicidal, one of the latter surviving ; in 6 of these one of the greater 
cornua was broken, in the remaining 2 the body. Gibb 1 says that Mack- 
murdo, a surgeon of Newgate prison for many years, found this frac- 
ture only four times on examination of the bodies of those who met their 
death there by hanging. In the other cases of the list the cause was 
violent grasping of the neck, or a blow, or fall, and in two cases appa- 
rently muscular action, general muscular contraction during a fall. Val- 
salva reports a case of " dislocation of one of the greater horns from the 
body," caused by the effort to swallow a large piece of food. 

In the great majority of the cases the fracture was of one of the 
greater cornua, and usually at or near its junction with the body. In 
only three cases was the body of the bone broken, and in none the 
lesser horn. 

The symptoms of fracture of one of the larger cornua, without accom- 
panying injury of the larynx or trachea, are, according to the records, 
quite well-defined and characteristic ; sharp pain at the seat of fracture 
increased by pressure, speaking, or swallowing ; swelling in the same 
region appearing soon after the accident and due in part to extravasated 
blood ; recognizable displacement or mobility of the fragment ; crepita- 
tion ; and sometimes free bleeding into the mouth, the result of perfora- 
tion of the mucous membrane of the pharynx by the bone. Exploration 
of the pharynx will enable the surgeon to recognize displacement of the 
horn inward and perforation of the mucous membrane if they exist. 
The patient is seldom able to move the tongue freely or without pain, 
and in some cases attempts to depress it or put it out have caused parox- 
ysms of suffocation. In all the cases it has been difficult or impossible 
to swallow, even a drop of water sometimes causing the patient to cough 
and choke, and in many of them it was necessary to give food through 
an oesophageal tube, in one case for twenty days. The patient finds it 
difficult to speak, and the voice is hoarse and low. 

In the single case in which a fracture of the body of the hyoid bone 
was observed during life the symptoms were severe paroxysms of cough- 

1 On the Dis. and Injs. of the Hyoid Bone, London, 1862, p. 44 ; quoted by Grurlt. 



296 



FRACTURES OF THE HYOID BONE. 



Fig. 154. 



ing, dyspnoea, lividity of the face, and abundant bloody sputa, and were 
relieved by the reduction of the displacement. 

The local and general reaction after the injury has been quite marked, 
and although the bone appears to have united promptly convalescence has 
been delayed by the persistence of the dysphagia and of the change in 
the voice. In one case an abscess formed at the seat of fracture, and 
three months afterwards the necrosed posterior fragment was cast out. 

The possibility of repair by a bony callus is shown by two specimens ; 
one, taken from the body of an adult man without a history and pre- 
sented to the London Pathological Society by Gibb, showing a fracture 
of the right greater horn which had united with overriding to the extent 

of one-quarter of an inch, and displace- 
ment inward ; the other (fig. 154) in 
the pathological collection of the college 
at Brunswick, showing a fracture of the 
right greater horn united with some 
shortening and displacement downward. 
The prognosis, so far as life is en- 
dangered by the injury to the bone, is 
favorable, but the associated injuries 
in the recorded cases have often been 
such as to cause death. Among these 
associated injuries fracture of the car- 
tilages of the larynx is prominent. 

The treatment requires the reduction 
of displacement, if possible ; and this 
may sometimes be facilitated by the introduction of the finger into the 
pharynx. It is unlikely that a bandage would be of any service in op- 
posing a tendency to the recurrence of displacement. The dysphagia 
may render nourishment through an oesophageal tube necessary, and the 
inflammation of the soft parts may require active local treatment. 




United fracture of the hyoid bone. (Gurlt.) 



CARTILAGES OF LAKYXX AXD TRACHEA. 297 



CHAPTER XVI. 

FRACTURES OF THE CARTILAGES OF THE LARYNX AND TRACHEA. 

This injury, although actually rare, is more frequent and much more 
dangerous than fracture of the hyoid bone and has received more atten- 
tion from writers. Gurlt's collection, published in 186-1, contained 47 
cases, Dr. Hunt 1 collected and analyzed 27 cases but did not give the 
details, and Henoque 2 collected 52 cases, to which Mr. Durham 3 added 
10, making 62 in all, or including 4 of Gurlt's in which the trachea 
alone was injured Q6. 

The following table shows the relative frequency with which the differ- 
ent parts are affected: — 



Cartilage broken. 


Cases. 


Deaths. 


.Recoveries. 


Thyroid alone .... 


. 24 


18 


6 


Cricoid alone .... 


. 11 


11 




Thyroid and hyoid bone 


. 4 


2 


2 


Thyroid and cricoid 


. 9 


9 




" " " and hyoid bone 


2 


2 




" "' " and trachea . 


.' 2 


2 




Cricoid and trachea 


2 


2 




" " " and hyoid bone 


.' 1 


1 




"Larynx" 


. 7 


3 


4 


Trachea alone .... 


. 4 


3 


1 



66 53 13 

The causes are blows, falls, hanging, and the grasp of the hand in a 
fight, or in an attempt to strangle. The injury is seen more frequently 
in males than in females, and in middle life than at any other period, 
but youth and old age are not exempt. The mechanism of the fracture of 
the thyroid or cricoid is usually either lateral compression on both sides 
or pressure backwards against the vertebral column ; the first causes 
commonly longitudinal fracture of the thyroid cartilage near its middle, 
together with flattening or depression of its sides, and either a double 
lateral fracture of the cricoid cartilage or a single fracture in the anterior 
median line ; the second causes irregular and multiple lines of fracture. 
The mucous membrane of the larynx is frequently torn, and extravasa- 
tions of blood take place under the skin and mucous membrane or among 
the muscles. 

The symptoms of fracture of the larynx are frothy bloody expectora- 
tion with convulsive coughing and usually much dyspnoea and its atten- 
dant symptoms. The voice is affected or lost, and swallowing often 

1 Am. Journal Med. Sciences, April, 1866, p. 378. 

2 Gazette Hebdomadaire, Sept. 25th and Oct. 2d, 1868. 

3 Holmes's System of Surgery, Am. ed., vol. i. p. 697. 



298 CARTILAGES OF LARYNX AND TRACHEA. 

difficult and painful, although not so much so as after fracture of the 
hyoid bone ; and in all severe cases, when there is laceration of the 
mucous membrane, emphysema appears promptly and spreads steadily 
over the neck, face, trunk, the extremities, and mediastinum, being some- 
times more marked in the intermuscular than in the subcutaneous con- 
nective tissue and sometimes causing pneumothorax without wound of 
the lung. 

The additional objective symptoms are deformity of the region and 
abnormal mobility of parts of the larynx upon each other, but both these 
signs may be unrecognizable on account of the swelling. 

In some cases there have been no marked symptoms beyond a change 
in the voice, although the character of the injury was made clear by 
careful examination, and the difference seems to be due to the absence 
in these cases of any obstruction or narrowing of the air passages by 
displaced cartilages. 

The course in the severe cases is towards prompt death by suffocation, 
either by gradual increase of the dyspnoea or by the sudden intercur- 
rence of oedema of the glottis. Occasionally the dyspnoea does not 
make its appearance until some days after the injury. In the mild cases 
the symptoms gradually subside, and recovery follows. 

It seems probable that repair is by a bony, or at least by a calcified, 
callus. 

The treatment in the milder cases consists of local antiphlogistics and 
quiet ; in the severer ones, of tracheotomy whenever the dyspnoea is 
great or increasing. It is not safe to wait until it has become extreme, 
for its increase at the last is often so rapid and sudden that death takes 
place before relief can be given. It is therefore the part of prudence 
to interfere early and before the interference is made actually necessary 
by the defective breathing. Advantage should be taken of the oppor- 
tunity afforded by the operation to reduce any displacement that may 
exist and that can be overcome by manipulation through the wound. 

The symptoms of fracture of the trachea are similar to those of frac- 
ture of the larynx, except the local ones due to the displacements ; the 
diagnosis is difficult because of the lack of symptoms distinctive of the 
seat and character of the lesion. The prognosis is unfavorable, and the 
treatment usually insufficient to avert the fatal termination or relieve the 
suffering, because in the few recorded cases the seat of injury has been 
beyond reach by operation. The indication for treatment is to insert 
a tube into the trachea past the point of fracture so as to insure free 
breathing. 



FRACTURES OF THE STERNUM. 



299 



CHAPTER XVII 



FRACTURES OF THE STERNUM. 





The sternum, formed originally of several pieces, has an irregular 
and uncertain development, only one feature of which, however, needs 
to be mentioned in this connection. The up- 
per portion, the manubrium, usually unites 
by ossification with the central portion, the 
body, during the early period of adult life, 
but sometimes this union is delayed or actu- 
ally given up, and in the latter case the con- 
nection between the two parts may be a real 
joint with cartilages of incrustation, a capsule, 
and synovia. A traumatic separation of these 
two portions under such conditions, is a dislo- 
cation or diastasis rather than a fracture, but 
as the distinction cannot always be recognized 
with certainty upon the patient, and as the 
symptoms and treatment are the same in 
either case, it seems advantageous to follow 
the general custom and describe all cases as 
fractures. The pathognomonic sign of a dis- 
location or diastasis, according to Malgaisme, 
is the recognizable outline of the articular 
border, usually the upper one of the second 
portion of the bone, which presents three fa- 
cets, a central one for articulation with the 
manubrium, and one at each angle facing 
upward and outward for articulation with the 
second rib (fig. 155). 

The great rarity of the accident is clearly 
shown by statistics, only 22 cases appearing 
in the 22,616 fractures of all sorts treated 
during twenty years at the London Hospital 
(see table page 35), less than one-tenth of 
one per cent. It is unknown in childhood, 
the earliest recorded instances being one at 
the age of 15 years, one at 18 years, and a 
doubtful one at 14 years. As it is usually 
caused by great violence it has frequently 
been found associated with other fractures, 
especially with those of the ribs and vertebrae. 

The fracture may be incomplete, multiple, transverse, oblique, or 



Diastasis of the sternum. 
(Malgaigue.) 

Fior. 156. 




Longitudinal fracture of the 
sternum. 



800 FRACTURES OF THE STERNUM. 

longitudinal. Of the first form there are but two recorded instances ; 
in both the infraction occupied the posterior surface of the bone at or 
near the junction of the lower and middle thirds, was transverse in one 
and oblique in the other, and in each was accompanied by an abundant 
extravasation of blood into the anterior mediastinum. One was caused 
probably by the kick of a horse, the patient being found dead upon the 
floor of a stable, the other by a fall upon the head from a height of 
about ten feet. 

Of compound fractures, except such as were gunshot or stab wounds, 
there is but one example, reported by Duverney in 1751. A quarry- 
man, while at work lying upon his side, was caught under a heavy stone 
about five feet long which compressed his chest laterally with such force 
as to separate the middle portion of the sternum from the upper portion 
and force it through the skin. Death was immediate, by rupture of the 
heart and lungs. 

Of pure longitudinal fracture there is but one certain example, 
although there are two other cases in which there was a longitudinal 
fracture of the manubrium or of the body of the sternum associated in 
one of them with a transverse fracture at the junction of these two parts, 
and a third in which the diagnosis of longitudinal fracture, based upon 
the history of the case and the presence of a supposed callus, was made 
several years after the occurrence of the accident which was supposed 
to have caused the fracture. The first case was that of a man who was 
overthrown and crushed by a falling wall ; in addition to numerous con- 
tusions, the sternum was broken longitudinally throughout its entire 
length, the right half being depressed from 8 to 10 lines below the level 
of the left half. There was profuse bloody expectoration and difficult 
breathing. Reduction was accomplished by drawing the right arm back 
and making forcible pressure upon the middle of the sternal ribs of the 
right side and gentle pressure upon the left side. The patient recov- 
ered in six weeks. 

In the doubtful case the supposed fracture was caused by muscular 
action ; the patient, a lad of 14 years, Avhile quarrelling with comrades, 
retreated into a corner, fixed himself there by pressing with his hands 
upon the walls, and defended himself by kicking. While thus engaged, 
he felt a sudden slight pain in the breast, and found himself unable to con- 
tinue the pressure with his hands. A few years later he studied medi- 
cine, his attention was directed to fractures of the sternum, and, recalling 
this incident of his youth, he suspected a fracture and had himself ex- 
amined, in 1798, by several surgeons, who found what they supposed to 
be a callus occupying the centre of the bone along its entire length. 

Cases of congenital fissure of the sternum have been reported as 
longitudinal fractures. 

Simple transverse fractures form the great majority of fractures of the 
sternum, and occupy most frequently the junction between the manu- 
brium and the body of the bone or its immediate neighborhood, that is, 
the region of the second intercostal space ; next in frequency are frac- 
tures at or near the middle of the bone, corresponding to the third rib 
and the third intercostal space ; they are rare in the manubrium and 



FRACTURES OF THE STERNUM 



301 



below the middle of the bone, and very uncommon as separations of the 
ensiform appendix from the body. 

Fractures of the manubrium occur, according to the few cases in 
which their position has been accurately described, most commonly a 
short distance, two or three lines, above the lower border of this portion 
of the bone ; the periosteum sometimes remains untorn upon either the 
anterior or the posterior surface ; in some cases there has been no dis- 
placement, in others either the upper or the lower fragment has been 
displaced forward, and in one case there was angular displacement, the 
apex of the angle being directed inward. In several of the cases the 
fracture was produced by muscular action, by straining during childbirth, 
or by the effort to raise a heavy weight with the teeth, the body being 
bent far back. In a large proportion of cases in which the lesion was 
produced by external violence, there was also fracture of the ribs, clavi- 
cle, or vertebrse. 

Partial fractures have been observed in two instances, once in connec- 
tion with fracture of the ribs, a scale of bone corresponding to the arti- 
culation with the first rib being broken off ; a second time in connection 
with dislocation of the sternal end of the clavicle, the portion to which 
the sterno-cleido-mastoid was attached being torn off and drawn upward 
nearly half an inch ; and in a third case in connection with a transverse 
fracture lower down. 

Transverse fracture at or near the junction of the manubrium and 
body of the bone, and diastasis at this point, which is not always to be 
distinguished from fracture, are the commonest forms of injury. In the 
great majority of cases the lower fragment is dis- 
placed so as to lie in front of the upper one, and 
sometimes to override ; it is exceptional for displace- 
ment to be absent or for the upper fragment to lie in 
front of the lower one. 

There is reason to think that the periosteum is 
almost invariably torn upon the anterior surface, 
but that it sometimes remains untorn behind, a fact 
which derives considerable importance from its bear- 
ing upon the escape of blood into the anterior 
mediastinum. One or both of the second pair of 
ribs usually remain attached to the manubrium. 

Out of a total of 105 cases of fracture of the 
sternum collected by Gurlt, 27 are described as 
partial or complete diastasis at the junction of the 
first and second portions, the character of the lesion 
having been determined by post-mortem examination 
in fourteen of them. 

Fractures of the body of the sternum (fig. 157) 
occur most frequently between the second and fourth 
costal cartilages, are usually transverse, but some- 
times oblique laterally or from before backward. 
The displacements are the same as after frac- 
ture at the i unction of the manubrium and sternum, 

-■ . . , " Transverse fracture of 

and there is the same relative frequency of the the body of the sternum. 



Fi-. 151 




302 FRACTURES OF THE STERNUM. 

projection of the lower fragment. Sometimes the fragments move 
quite freely upward and downward upon each other during the acts of 
respiration. 

Comminuted fracture of the body of the sternum has been rarely 
seen except in connection with gunshot and punctured wounds. Of 
triple fractures Gurlt found only two cases, and of double fractures 
only six, all of them associated with fracture of other bones, usually 
the ribs or vertebrae. 

Of fracture or diastasis of the ensiform appendix, Gurlt collected only 
four examples, and the list does not appear to have been increased by 
subsequent writers ; one was a fracture, the other three diastases. The 
fracture was produced in a man sixty years old, by a fall upon the 
sharp edge of a grain measure, and, when last examined, nine months 
after the accident, was still ununited and crepitated on pressure, but 
caused no inconvenience. In the other three cases the prominent 
symptom was persistent vomiting, which in one lasted for two years, 
recurring every five or six days, and then ceased spontaneously ; in 
another it was cured by grasping the process between two fingers, and 
bending it back into place ; and in the third, after it had lasted a month, 
and death by exhaustion seemed imminent, it was instantly relieved by 
the reduction of the displacement, which was accomplished by inserting 
a blunt hook into the abdominal cavity through an incision, and draw- 
ing the process forward. The patients were aged respectively 28, 18, 
and 19 years. 

The effusion of blood, which is observed after all fractures, may attain 
an especial importance after fracture of the sternum, by the pressure 
which it may exert upon the underlying heart. The blood, coming from 
the torn vessels of the bone and periosteum, makes its way forward into 
a region where it can do no harm, if the periosteum on the posterior 
surface remains untorn ; but if this membrane shares in the injury, and 
especially if one of the internal mammary veins or arteries is ruptured, 
the blood makes its way into the anterior mediastinum, and sometimes 
in sufficient amount to cause death promptly. 

Rupture of the pericardium, or of the heart, has been observed in a 
few cases ; as has also probable laceration of the lung, evidenced by the 
appearance of subcutaneous emphysema or pneumothorax. 

Etiology. — Fracture of the sternum may be produced either by mus- 
cular action or by external violence. 

There are four recorded cases in which the bone has been broken by 
straining during labor, and three in which the fracture has occurred 
during an effort to lift a heavy object. An example of the former has 
been quoted in Chapter IV. ; the following is an example of the latter. 

A woman was trying to lift a heavy basket into a wagon, and, while 
standing with her head and shoulders thrown back and the basket rest- 
ing against her belly, felt something crack in her chest with pain. A 
transverse fracture of the manubrium, two lines above its lower border, 
was recognized, with displacement forward of the lower fragment, ab- 
normal mobility, and sharp pain on raising the chin, moving the arms, 
or coughing. 

External violence acts either directly by a blow upon the breast, or 



FRACTURES OF THE STERNUM. 303 

indirectly by forcibly bending the body forward or backward, or possi- 
bly by a combination of the two forms in the fall upon the body of a 
heavy object, or the passage across it of a loaded wagon. It is not 
necessary that the force which acts directly should be very great to 
produce fracture ; it is sufficient for it to act upon a limited area, as in 
a fall upon a stone, or stick, or the edge or corner of a box. 

The violence which produces indirect fracture is, in most cases, a fall 
either upon the shoulders or buttocks, or with the back or breast across 
some fixed object, so that the trunk is bent sharply forward or backward ; 
in the one case the bone is broken by being bent forward, in the other 
by the traction exerted through the muscular attachments at either end. 

The diagnosis is readily made by the objective symptoms, the dis- 
placement, mobility, and crepitation, by the localized area of pain 
excited by pressure, change of position, and the more violent respiratory 
acts. The position of the patient, too, is often characteristic, for the 
shortening; of the sternum bv the overriding of the fragments and the 
pain that is excited by traction upon the fragments lead him to keep a 
semi-recumbent or sitting position with the head and shoulders bent 
forward, and to carefully avoid any movement that tends to straighten 
the trunk. The examination of the bone must be made carefully in 
order, on the one hand, to avoid mistaking some irregularity of develop- 
ment for a traumatic displacement, and, on the other, not to overlook a 
second or third fracture, or even a single one in case there should be no 
displacement. The condition of the adjoining costal cartilages may be 
of much service in doubtful cases, such as diastasis at the junction 
of the first and second portions without displacement; thus, if the second 
costal cartilage on either side is found to project at its point of junction 
with the sternum, and especially if the projection can be reduced by 
pressure, the fact points strongly toward a diastasis. In cases of sup- 
posed injury to the ensiform appendix the frequent irregularities in the 
shape, position, and mobility of that part must be borne in mind. 

The importance of the injury is by no means so great as the mortal- 
ity of the recorded cases would indicate, for this mortality is largely 
due to associated lesions. Gurlt tabulated 98 cases with reference to 
this point, among others, and found that of 54 simple cases 46 recovered 
and 8 died, while of 44 complicated cases, cases, that is, in which there 
was some severe associated injury, only 1 recovered and 43 died. Of 
20 cases in which the fracture was certainly caused by direct violence, 
15 recovered, and 5 died, 3 of the latter being complicated cases. A 
mortality of 8 in 54 cases is high enough to prove the importance, the 
seriousness, of the injury, but so far as can be learned from an examina- 
tion of the records it is not certain that the death was due to the frac- 
ture in all of them ; thus, in the case quoted in Chapter IV., of fracture 
by straining during childbirth, and in another very similar one published 
by Chaussier, death was caused by peritonitis, and although an abscess 
was found at the seat of fracture it seems probable it was the conse- 
quence rather than the cause of the constitutional infection. 

In the following case, 1 on the other hand, the injury itself was appa- 

1 Yirclicvr, Gresanurtelte Adhandlungen, p. 579, quoted by Gurlt. 



304 FRACTURES OF THE STERNUM. 

rently the sole cause of death. A man 25 years old was struck in the 
breast by the pole of a rapidly moving wagon ; he lost consciousness at 
first, and complained after recovery of oppression and great pain in the 
chest. A chill occurred on the fifth day and was followed by several 
others ; death on the eighth day. The autopsy showed a transverse 
fracture at the fourth intercostal space without rupture of the fibrous 
lining of the bone, extensive disorganization of the adjoining soft parts, 
especially the anterior mediastinum, purulent thrombosis of the right 
mammary vein, secondary pleurisy, pericarditis, and perihepatitis, with 
phlebitis at points where venesection has been made. 

In another case reported by Duverney, in 1751, a comminuted frac- 
ture produced by moderate violence caused immediate death by lacera- 
tion of the heart by the fragments. A young man playing skittles 
leaned forward after casting the ball to watch its effect and fell, striking 
his breast upon a stone and dying instantly. The body of the sternum 
was broken, the fragments pressed inward, the pericardium opened, and 
the right auricle torn in three or four places. 

The course in the less severe cases is an uneventful one ; in the only 
uncomplicated case which has come under my care, the patient, a man 
of 60 years, who had received his injury by the fall of a frame building, 
complained only of pain on pressure and on drawing a long breath, was 
able to lie upon his back from the first, and was soon dismissed cured, 
but with a slight projection of the upper end of the lower fragment. If 
pain and oppression are more marked at first they soon diminish and 
disappear, as do also the expectoration of blood, dyspnoea, and orthop- 
noea. In exceptional cases the local reaction may be great and may 
lead even to the formation of an abscess about the fracture. The pus 
may make its way to the surface between the fragments or on the sides, 
and if pulsation is communicated to it by the underlying vessels the 
surgeon may mistake it for a traumatic aneurism. If it collects upon the 
posterior surface and is discharged imperfectly through a small opening, 
the fistule may persist indefinitely, or the unnatural conditions may lead 
to extensive caries of the bone. Both conditions require treatment by 
active operative interference. 

Usually repair takes place in from four to eight weeks, and by a bony 
callus. The persistence of a certain degree of displacement is not un- 
common, and in some cases the deformity has been extreme. One is 
reported in which the bone had been driven in so far by the kick of a 
horse that it was almost in contact with the spinal column and left a 
depression in front in which the head of a six-year-old child could rest. 
The displacement had persisted for ten years, but the patient was per- 
fectly well and there were no notable disturbances in respiration or cir- 
culation. 

Failure of bony union has been observed in a few cases, but does not 
appear to have caused any disability beyond a temporary difficulty in 
abduction and adduction of the arms. 

Gunshot fractures may be penetrating or non-penetrating. A number 
of illustrative cases of each kind are given in the Surgical History of the 
War of the Rebellion. The latter do not differ materially from com- 



FRACTURES OF THE STERNUM. SQ& 

pound fractures due to any other cause, but in the former the prognosis 
is rendered very grave by the associated lesions. 

Treatment. — The first indication is to reduce such displacement as 
may exist. This is not always possible ; the most intelligently directed" 
and persistently conducted efforts have sometimes failed. The usual 
method is direct pressure upon the projecting fragment, aided, espe- 
cially when there is overriding, by traction upon the two pieces. The 
traction must be made, in part at least, through the muscles attached 
to the ends of the bone, and is accomplished sometimes by resting the 
back upon some rather firm object, as a cushion or box, and bending the 
head and shoulders forcibly backward. At the same time the patient 
may be directed to take a full inspiration, and the surgeon presses 
downward against the upper edge of the lower fragment if that one, as 
is usual, projects, or he draws this fragment downward by taking hold 
of the projecting ribs that are attached to it. Various modifications of 
the plan have been employed but all have the same fundamental idea, 
that of traction in opposite directions upon the fragments by forcible 
bending of the body backward. 

A number of operative methods have been proposed for use in those 
cases in which the displacement cannot be reduced by manipulation, 
such as to raise the depressed fragment by a sort of gimlet screwed into 
it, or by an elevator or blunt hook passed under it through an incision, 
or to cut away the projecting portion with the knife or trephine, or to 
press it back with a rod carried directly down to it through an incision. 
Most of these remain as suggestions that have not been put to the test. 
One case has been already mentioned in which the ensiform appendix 
was drawn forward successfully by means of a blunt hook passed into 
the peritoneal cavity ; in another, of fracture at the upper part of the 
sternum with depression of the lower fragment, an incision was made 
with the intention of introducing a hook, but the pleural cavity was 
opened and the surgeon felt it necessary to close the w T ound immediately. 
In another the upper fragment was raised to the proper level by screw- 
ing a sort of gimlet into it and drawing it forward, but it afterwards sank 
partly back again, and a second attempt to raise it was defeated by the 
tearing out of the screw. In a compound fracture caused by a blow with 
a bayonet the depressed fragments were raised with a spatula and one 
of them was entirely removed. The patient recovered after two narrow 
escapes from death by hemorrhage. 

Unless the displacement is actually causing dangerous or distressing 
symptoms these methods of removing it by operation are not justifiable, 
because they carry with them risks that should not be lightly run. The 
pleural or abdominal cavity cannot be opened without danger of setting 
up a fatal inflammation, and the conversion of a simple fracture of the 
sternum into a compound one exposes to the chance of suppuration within 
the anterior mediastinum. On the other hand, the displacement usually 
involves no disability and no apparent or noticeable deformity. 

The subsequent treatment consists in immobilization of the chest, and, 

if necessary, in the use of measures to allay local inflammation and to 

prevent coughing. A convenient dressing is a broad flannel bandage 

pinned tightly about the chest after forced expiration, or bands of adhe- 

20 



306 FRACTURES OF THE STERNUM. 

sive plaster extending from side to side across the front of the chest and 
covering the entire length of the sternum. 

The trephine has been occasionally used to seek for and evacuate an 
abscess supposed to have formed behind the bone, but most authorities 
decline to recommend the measure, because of the uncertainty of the 
diagnosis, and advise that the surgeon should wait for the pus to make 
its appearance either between the fragments or on the side. Agnew 1 
did the operation once and with a satisfactory result, but adds that he 
thinks it is better to wait. The justification for delay must be found in 
the difficulty of making the diagnosis, and as the risks attendant upon 
the operation when performed with antiseptic precautions are certainly 
less than those arising from a confined and growing abscess I should not 
hesitate to do an exploratory trephining if the symptoms indicated the 
presence of pus. The proper plan to pursue, in my judgment, would 
be to remove the disk of bone without division of the periosteum on the 
posterior surface, and then to seek for pus by puncturing in different 
directions with an aspirating needle. 

1 Surgeiy, vol. i. p. 860. 



FRACTURES OF THE RIBS AXD THEIR CARTILAGES. 307 



CHAPTER XVIII. 

FRACTURES OF THE RIBS AXD THEIR CARTILAGES. 

These are among the commonest of all fractures, constituting accord- 
ing to different statisticians from ten to eighteen per cent. Thus, ac- 
cording to Malgaigne, of 2358 fractures at the Hotel Dieu 263 were of 
the ribs ; of 2275 at Guy's Hospital 1 222 were of the ribs ; and of 
51,938 at the London Hospital, 2 including " out-patients," 8261 were of 
the ribs, or about 16 per cent. According to Malgaigne fractures of the 
ribs are almost unknown in infancy and childhood, his statistics contain- 
ing only three cases below the age of twenty years. Coulon 3 says that 
of 140 fractures in children observed by him at the Hopital St. Eugenie 
during one year the ribs were broken only once, and that time by the 
passage of a heavily laden wagon across the chest : several ribs were 
broken, the fractures were incomplete and were recognized only at the 
autopsy. He refers also to a confirmatory statement by Marjolin to the 
effect that he had not seen more than two or three fractures of the ribs 
in 800 or 900 cases of fracture observed in children. I have myself 
observed one case in a child 9 years of age which was not recognized 
until after an abscess had formed and exposed the necrosed fragments ; 
and taking that fact and Coulon's autopsy into consideration I am in- 
clined to believe that fractures of the ribs in children may be more com- 
mon than is supposed, but are overlooked because incomplete. They 
are much more common in men than in women. 

Pathology. — Fractures of the ribs may be partial or complete, simple 
or compound, single or multiple. Partial fractures may be constituted 
either by a fissure involving only one of the borders of the rib and, 
perhaps, separating entirely a longer or shorter fragment of that border, 
or by an infraction. The former is uncommon ; it was observed post- 
mortem in connection with complete fracture of other ribs by Lisfranc 
in a case quoted by Malgaigne, and was also produced experimentally 
by the latter. The fracture in Lisfranc's case is described as a longi- 
tudinal one running for one and a half or two inches along the lower 
border of the third rib ; that in Malgaigne's circumscribed a fragment 
of the lower border of the fifth rib. 

Infractions are similar to those seen in the long bones, that is, there 
is complete fracture on only one side of the rib ; the periosteum is usually 
untorn. They constitute, as a rule, only a slight injury, and are there- 
fore seldom seen post-mortem, except when associated with other frac- 
tures of the ribs, or with other injuries. A remarkable case of death 

1 Holmes's System of Surgery, Am. ed., vol. i. p. 747. 

2 See Table on p. 35. 

3 Traite des Fractures chez les Enfants, 1861, p. 87. 



308 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

by hemorrhage after partial fracture of the eighth rib is quoted by Gurlt 
from the London Medical Times and Gazette, 1860, vol. ii. p. 607. 
The fracture was caused in a man, thirty years old, by a blow with a 
light cane, which left no mark upon the surface. Symptoms of collapse 
soon appeared, and death in seventeen hours. Five pints of blood were 
found in the right pleural cavity, and appeared to have come from a 
small rent in the pleura corresponding to a fracture of the inner surface 
of the eighth rib, about two inches from its anterior end. A small 
branch was found to leave the intercostal artery close to the rent and to 
pass toward it. 

Complete fractures may be transverse, oblique, irregular, or multiple, 
and may be limited to a single rib, or may involve all the true ones on 
one side, and in some cases even many on both sides. The central ribs 
are the ones most frequently broken, while the first and the floating ribs 
almost always escape. The fracture may occupy any part of the rib ; 
Malgaigne thinks it is more common in the anterior portion than else- 
where, and Hamilton says his own observation confirms this opinion. 
Agnew, on the contrary, says it does not accord with his experience of 
cases treated or specimens examined, most of which showed fracture in 
the posterior half. Malgaigne says he never knew a case of comminution 
except in gunshot fractures, and was never able to produce it experi- 
mentally. 

The periosteum may remain untorn, and the fragments preserve their 
relations to each other, or they may form a re-entrant or a salient angle, 
or override each other by their sides or edges. If several ribs are 
broken completely or partially at the same time and forced inward, the 
depression may remain both broad and deep. Overriding of the fragments 
is impossible unless several ribs are broken at the same time, for the 
muscular and fibrous attachments of the adjoining ones hold the frag- 
ments in place, and the ribs above and below act as splints to prevent 
shortening. When several ribs are broken at the same time the side 
sinks in, and thus shortening and overriding are made possible. In at 
least five cases of double or multiple fracture of one or several ribs the 
intermediate piece or pieces have been so loosened that they moved in 
and out with every inspiration. Malgaigne quotes one of these cases as 
a very exceptional fact ; Gurlt gives the details of five additional ones, 
two of which I reproduce briefly. 

Midcleldorpf saw a woman, sixty-three years old, with an extensive 
multiple fracture of the ribs on the right side, caused by a fall upon the 
edge of a tub; there was extensive emphysema of the right half of the 
body, and hemothorax. At each inspiration the side of the thorax w r as 
drawn in, and at each expiration it was forced out again. Recovery in 
fifty-four days. 

Wutzer and C. 0. Weber saw a man, fifty-six years old, over the 
right half of whose chest a heavy cart had passed from below upward, 
breaking all the ribs on that side except the first and the last, most of the 
fractures being double, and the intermediate fragment corresponding in 
length to the breadth of the wheel. The fragments of the fifth, sixth, 
seventh, and eighth ribs were entirely loose, and moved in and out with 



FRACTURES OF THE RIBS AND THEIR CARTILAGES. 809 

a distinctly audible crepitation each time the patient breathed. The 
patient died on the third day. 

In compound fractures the wound is rarely, if ever, caused by the 
projection of the broken end of the rib, but always by the object which 
produced the fracture. 

The complications include injuries to the muscles, which are rarely 
important, to the intercostal arteries, and to the thoracic and abdominal 
viscera. The intercostal arteries appear to be very rarely injured ; one 
instance has been mentioned already in which hemorrhage from a small 
branch of the artery followed incomplete fracture and caused death. 
Gurlt gives three additional ones, two of which terminated fatally ; in 
the remaining one an aneurism formed which was cured in about six 
weeks by pressure, rest, and restricted diet. Laurent 1 quotes another 
of a man twenty-nine years old, who was standing with his breast rest- 
ing against the edge of a bridge, when a friend sprang unexpectedly 
upon his back. It caused extreme pain in the breast, and an elastic pul- 
sating tumor formed at the spot. Twelve days afterwards the breast 
was as Jarge as that of a woman twenty years old ; its border was hard, 
its pulsations plainly visible to the eye ; it w r as not diminished by pres- 
sure, and gurgling was heard in it on auscultation. Fracture of the 
fourth rib was recognized. It was treated by repeated bleedings, with 
internal administration of ice, ergot, and digitalis. Two days afterwards 
the patient had a sudden attack of suffocation, with small pulse and 
nausea, and the tumor disappeared, leaving only the hard border ; at the 
point of fracture w r as a gap, into which the index finger could be intro- 
duced, and where pulsation could be felt. The right arm had been 
paralyzed since the preceding day. The patient remained very ill for 
three days and then slowly convalesced. In March, 1868, Panas 2 men- 
tioned, in the course of a discussion in the Sociefe de Chirurgie, still 
another fatal case, which had come under his observation ten years 
before. 

A wound of the pleura and of the lungs is a rather common compli- 
cation, and is generally caused by the sharp end of a fragment, but in 
some cases fatal injury of the lung has been caused by the crushing 
effect of the external violence acting through the, perhaps unbroken, 
ribs ; the thorax is compressed by the force, and the lung is put upon 
the stretch in such a manner that it is actually torn, not perforated by 
the bone. The case quoted from Coulon at the beginning of this chap- 
ter illustrates this point, the fractures were incomplete, but the lung w T as 
torn in two places, one rent being in the upper lobe, the other at the 
bottom of the fissure between the upper and middle lobes. Legros Clark 3 
mentions two similar cases ; in one the sixth, seventh, and eighth ribs 
were broken near their angles by a blow from the shaft of a wagon, and 
there was a large rent across the lung, but no perforation of it by the 
ribs ; in the other, a child that had been run over, the lower lobe of the 
lung had been torn almost across, and, " although some ribs were broken, 

1 Des anevrysmes compliquant les Fractures. These de Paris, 1874. 

2 Gaz. des Hopitaux, 1868, p. 180. 

3 Diagnosis of Visceral Lesions, pp. 208 and 209. 



310 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

the pleura was not wounded." The consequences of the wound vary 
with its size and with the relations existing between the lung and the 
thoracic wall. If these latter are normal, that is, if the lung is not adhe- 
rent at the wounded part, air and blood escape more or less freely into 
the pleural cavity, and the lung collapses ; if, on the other hand, the lung 
is adherent, the escaping air makes its way into the meshes of the con- 
nective tissue, and may spread through the mediastinum, under the peri- 
cardium and pleura, and into the interlobular tissue of the lung itself and 
the subcutaneous tissue on the surface of the body. Emphysema of the 
surface may be produced "also when the lung is not adherent ; the air 
which has escaped into and filled the pleural cavity is forced by the con- 
traction of the chest during expiration out through the opening at the 
fracture, and its place is supplied at the next inspiration by fresh air 
drawn in through the wound of the lung, and thus a small quantity is 
pumped into the outer cellular tissue at each respiration, and this will 
continue until one or the other opening is closed by a clot or exudation 
or a change in the relations of its walls. The following cases will serve 
as illustrations : — 

1. A man 1 received a violent blow in the side from the pole of a 
wagon ; this was followed by coughing, slightly bloody expectoration, 
symptoms of suffocation, almost imperceptible pulse, and livid face. A 
circumscribed tumor appeared about an inch from the vertebral column, 
and became tense at each cough, with a sound like that of enclosed air. 
Emphysema spread over the breast and back, and was relieved by scari- 
fications through which the air escaped with a hissing sound. The 
paroxysms of coughing became more frequent and violent, the dyspnoea 
increased, and death took place on the third clay. The autopsy showed an 
oblique fracture of the " second and third last ribs" (eighth and ninth ?), 
two finger-breadths from their articulation with the spine ; there was an 
opening as large as the end of the finger in the intercostal muscles and 
pleura, and a wound in the lung corresponding exactly to one of the 
broken ribs. 

2. An old man 2 was thrown down and trodden under foot ; several 
ribs were broken, and there was enormous emphysema of the body and 
neck with great dyspnoea, bloody expectoration, and small pulse. The 
autopsy showed a large quantity of air in the anterior and posterior 
mediastina and throughout the interlobular connective tissue of the lung ; 
three ribs were broken on the right side, and there was a deep laceration 
of the right lung. 

3. A man 3 was crushed between two railway wagons, and sustained 
fracture of five ribs — second to sixth — in front and behind, with extreme 
prolonged collapse and expectoration of blood and mucus. A tumor larger 
than an inflated sheep's-bladder appeared over the seat of the fracture, 
was distended at each respiration, and spread over more than half the 
body. Several punctures were made and a bandage applied ; as the 
latter did not properly restrain the rising end of the second rib a spring 

1 Cheston, Pathological Inquiries and Observations. 

2 Dupuytreii, Lemons Orales, 2d ed., vol. ii. p. 210. (Griirlt.) 

3 Provincial Med. and Surg. Journal, 1851, p. 488. 



FRACTURES OF THE RIBS AND THEIR CARTILAGES. 311 

truss was added, and the fractured ends were thus kept in apposition. 
The patient expectorated a considerable quantity of pus streaked with 
blood, but made a complete recovery in six weeks. 

Wounds of the heart are much rarer, and even more dangerous. G-urlt 
collected six cases, in only four of which the wound of the heart appears 
to have been caused by the broken rib ; in the other two it appears to 
have been caused by the compression of the heart between the anterior 
chest-wall and the vertebral column, for the pericardium was untorn. 
The two following cases, from the Dublin Journal of Medical Sciences, 
1837, vol. ii. p. 174, illustrate the two varieties: — 

1. A brewer's man fell under a heavily laden dray, which passed over 
his chest. He was lifted up, complained of pain and weakness, but was 
able to sit on the side of the dray and drive the horse for nearly an hour, 
when, being in the neighborhood of a hospital, he thought he would get 
himself examined. He walked in and lay on a bed, but, on turning on 
his side, he suddenly expired. At the autopsy " it was found that the 
fifth rib was fractured, and that the extremity of one portion had pene- 
trated the pericardium and right auricle of the heart ; it filled up the 
perforation of the pericardium, but had freed itself from the heart." It 
was thought it had remained in the heart until the arrival at the hos- 
pital, and that the sudden death was caused by a change in its position 
that allowed the blood to escape into the pericardial sac. 

2. A Avoman was crushed between a wall and a heavily laden cart and 
died almost instantly. Several ribs were broken and driven into the 
lungs. " The pericardium was distended with blood, the superior vena 
cava having been torn almost completely across from the right auricle." 

There are also a few cases on record in which a broken rib has perfo- 
rated the diaphragm, and even injured some of the abdominal viscera. 
Morgan presented to the Pathological Society of London the specimens 
obtained at the autopsy of a man who had died in consequence of a fall 
from a height of twenty-five feet. The sixth rib had perforated the 
pleura, the edge of the lung, the diaphragm, the ileum, and the spleen. 

Etiology. — Fractures of the ribs may be caused by muscular action 
or by external violence. Violent coughing has caused fracture several 
times, sneezing once, turning in bed twice, an effort to avoid falling 
while walking once, and the exertion made in straightening a scythe 
blade once. Usually it is one of the lower ribs that is thus broken, but 
it has happened also to the fourth, fifth, and sixth. While some of the 
patients have been old and decrepit and their bones possibly more fragile 
than usual, others have been young and vigorous. Malgaigne 1 claims to 
have observed a sort of senile atrophy in the ribs affecting especially 
their thickness and making them much more liable to break ; he says it 
is found also in connection with certain affections of the thoracic wall or 
viscera, and that he had seen it in a case of pulmonary emphysema and 
in one of cancer of the breast. In the latter case the tumor did not in- 
volve either the muscles or the ribs, yet the thickness of the latter was 
not more than one-third or one-fourth that of the ribs of the opposite 
side. 

1 Loc. cit., vol. i. p. 427. 



312 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

By far the most common cause of fracture is external violence, by a 
blow, fall, or excessive pressure. The fracture may be direct or indi- 
rect, the former being perhaps more common in advanced life by reason 
of the less elasticity of the bone, but it is not often easy to distinguish 
between these two varieties. In double fractures one is often direct. It 
has been claimed on theoretical grounds that in indirect fractures caused 
by pressure upon or near the sternal ends of the ribs the bone would 
yield near its centre, at its point of greatest curvature ; but this view is 
not supported by clinical or experimental facts. On the contrary, the 
fracture is found much more frequently in either the anterior or the 
posterior third, and indeed the point of greatest frequency seems to be 
very near that at which the force is received, an inch or two on the 
outer side of the sternal end of the bone. 

Gurlt gives in connection with this two cases of fracture of the twelfth 
rib, one direct, the other indirect, and as they are thought to be the 
only instances on record I reproduce them here. 

A girl 23 years old broke the twelfth rib on the left side by falling 
against the edge of a step. The fracture was two or three inches from 
the spine, there was much pain and crepitation. Recovery with notable 
displacement in four weeks. 

Legouest 1 saw a case of indirect fracture of the left twelfth rib in a 
man 48 years old, caused by a fall against the edge of a table. The 
pain at first was severe ; on the following day he was found in bed lying 
upon his right side with his head and shoulders well raised and breath- 
ing carefully and with short inspirations. Every movement caused pain ; 
there was an ecchymosis over the anterior third of the rib at the point 
where the blow was received. By pressing upon the end of the rib dis- 
tinct crepitation could be made out at the junction of the posterior and 
middle thirds. 

Symptoms. — The symptoms of fracture of the rib in the less severe 
cases are likely to be obscure. There is often acute pain, catching 
respiration, and cough clue, according to Legros Clark, probably to pres- 
sure upon, or injury to, the intercostal nerve, especially if the fracture is 
in the posterior portion of the rib. Pain is provoked by pressure, in- 
spiration, coughing, sneezing, and certain movements of the body, but 
this may also be the result of a simple contusion without fracture. If, 
however, it can be determined that the pain is felt at a point more or 
less distant from that upon which the blow fell, the fact points strongly 
toward indirect fracture. The same may be said of ecchymosis ; it may 
be due to contusion, but if found at a distance is a sign of fracture. 
Abnormal mobility is sometimes present, but the elasticity and mobility 
of the ribs make its recognition uncertain. It may sometimes be made 
out by placing a finger on each side of the suspected fracture, and press- 
ing alternately with one and the other. The same manipulation may pro- 
duce crepitation, but usually this is more readily recognized by placing 
the hand flat upon the chest, and pressing slightly at different points, or 
asking the patient to cough or draw a long breath. It may also be 
heard sometimes on auscultation of the chest, in the usual manner, and 

1 Gazette des Hopitaux, 1859, p. 65. 



FRACTURES OF THE RIBS AND THEIR CARTILAGES. 313 

may be accompanied after a day or two by a pleuritic friction sound, 
the result of a pleurisy excited by the traumatism, and usually limited 
in area to its immediate neighborhood. The difficulty of detecting 
either crepitation or abnormal mobility is even greater at those points, 
where the ribs are covered by a thick muscular layer, or when there is in- 
flammatory swelling, extravasation of blood, or emphysema. It is not 
uncommon for the patient himself to recognize the crepitation. Malgaigne 
saw a case in which, after fracture of the ninth rib, crepitation could be 
heard by those standing near the patient, whenever he made certain 
movements or drew a deep breath ; and he refers to another in which 
the pulsations of the heart produced the same effect. Emphysema is, 
in itself, a very positive sign of injury to the lung and of fracture of a 
rib if there is no penetrating wound to account for it otherwise. Pneu- 
mothorax, or hemorrhage into the pleural cavity from a lacerated lung 
or an intercostal artery may be present in any of the severer cases ; and 
bloody expectoration, which also points toward fracture, may be present 
in slight cases, and is not infrequently absent in grave ones. 

The symptoms of partial fracture or infraction are seldom definite 
enough to permit a positive diagnosis. 

The course of a simple uncomplicated fracture is usually quite un- 
eventful ; the patient remains quiet, sometimes keeping his bed, and 
breathes carefully and superficially to avoid pain ; after three or four 
weeks he finds these precautions unnecessary, and the surgeon finds on 

Fig. 158. 




Fractured rib three months after the injury was received. (Holmes.) 



examination that the local tenderness has disappeared, and that crepita- 
tion and mobility can no longer be detected. Union by a bony callus 
takes place almost invariably, notwithstanding the defective immobiliza- 
tion of the parts, but, as a consequence of the latter, the callus is likely 
to be large, and, when two or more ribs have been broken, to unite the 
adjoining ones by a bridge of new formation (fig. 159). Solidity is 
given at first by an ensheathing callus, and the union between the frac- 
tured surfaces, even when they are in apposition, may remain fibrous for 
several months. Failure of union is rare ; Malgaigne had met with 
only instance and had heard of only one other. The latter was found 
upon a cadaver, and was a case of real pseudarthrosis with capsule and 



314 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

synovial membrane. Paulet, 1 however, mentions four additional cases, 
and claims that it is by no means so uncommon as Malgaigne supposed. 
Displacement upward or downward of one or more of the fragments 
may lead to its union with the adjoining rib, or to the formation of a lateral 

Fie. 159. 




Fracture of the ribs ; exuberant callus. (Holmes's Syst.) 



joint between them, as in the next following case, and in the specimen 
of the forearm represented in figure 73 ; or, if adjoining ribs are displaced 
in opposite directions, a gap may be left between them which may lead 
to hernia of the lung, as in the following case which is recorded in the 
Gazette Medicate de Paris, 1832, p. 465, and pictured in Cruveilhier's 
Atlas d'Anatomie Patlioloyique. 

The patient died at the age of 62 years : in his youth he had sustained 
a fracture of the ribs by being crushed between the pole of a wagon and 
a wall. Between the third and fourth ribs on the right side near the 
sternum w r as a reducible tumor composed of normal lung and contained in 
a real hernial sac. The first rib was intact, the second and third were 
broken about three inches from their cartilages w T ith displacement inward 
of the anterior fragment, overriding, and a vertical displacement that 
brought the posterior fragments into contact and led to the formation of 
a false joint between them. The fourth rib was bent sharply downward, 
forming the lower limit of a gap that was four inches long, and two and 
a half inches wide at the widest part, and that was bounded above by a 
small strip of bone extending from the fourth costal cartilage along the 
lower border of the third rib, and becoming attached to the latter near 
its middle. 

A somewhat similar case is mentioned by Mr. Bryant 2 as having been 
under his care at Guy's Hospital in 1876. The sternal ends of the 
third and fourth ribs were broken and driven in without wound of the 
integument by a fall upon a wooden paling. " Hernia of the lung took 
place the size of a duck's egg, but an excellent recovery followed the 
reduction of the hernia and the peristent application of pressure." Still 
another case is described in the following section on fracture of the 
costal cartilages (p. 320). 

It occasionally happens, as in the personal case mentioned in the note on 

1 Diet. Encyclopedique, art. Cotes, p. 70. 

2 Practice of Surgery, 3d Amer. ed., p. 575. 



FRACTURES OF THE RIBS AND THEIR CARTILAGES. 315 

page 142, and in a few similar ones, that repair is interfered with by sup- 
puration and by caries or necrosis of the broken rib, and does not become 
complete until after the removal of the diseased bone or the sequestrum. 
The course and symptoms in the severer cases vary with the degree 
and character of the complications which give them their gravity. E 



°.: 



ui- 



physema may be slight and transitory, or it may continue for days and 
spread over a large portion of the surface of the body. If the air 
escapes into the cavity of the chest, or if the fracture is compound with 
a penetrating wound, the resultant dyspnoea and oppression may be 
extreme, and the physical signs of pneumothorax will be found upon 
examination. If, in addition to the escape of air, there is also free 
hemorrhage into the chest from the torn lung or an intercostal artery, 
the physical signs will be correspondingly modified. Extreme dyspnoea, 
due to congestion of the lung following promptly upon the injury, is not 
uncommon, and pneumonia occasionally results and leads to a fatal ter- 
mination in the old and feeble. 

Legros Clark 1 claims that serious functional derangement, without 
organic lesion of the lung, may result from contusion or concussion of 
the chest, that it may be transient or may be followed by inflammation, 
local or general, of the affected lung, and that it is sometimes observed 
in the lung on the side opposite that which has sustained the injury. 
He mentions illustrative cases of which I quote the following : — 

A lad 12 years old was brought to the hospital after a fall from a 
height of forty or fifty feet which had caused no recognizable injury 
except a few bruises on the trunk and a portion of the humerus. The 
shock was moderate. The next day he had a flushed face and hurried 
and oppressed breathing ; but, though the dyspnoea was urgent, there 
was neither lividity nor coldness of the lips or extremities. The heart's 
action was forcible and frequent, but the sounds were normal. Over the 
left side of the chest there was entire absence of resonance on percus- 
sion and of breath-sounds, and indeed of any sound but the heart's beat, 
except, perhaps, the feeblest murmur just below the clavicle. The 
vocal thrill was equally distinct on both sides. On the right side there 
was normal resonance on percussion, and the respiration was puerile. 
There was neither cough nor expectoration. Four leeches were applied 
over the upper part of the affected lung with almost immediate relief. On 
the following day the boy was breathing quietly ; and in less than forty- 
eight hours all the symptoms had disappeared. 

The prognosis depends largely upon the complications. Simple frac- 
tures without important complications do well as a rule ; the exceptions 
are found mainly in the old and feeble whose lives may be endangered 
by congestion of the lungs, pneumonia, or pleurisy. Cases complicated 
by wound of the heart or pericardium are usually promptly fatal. 
Wounds of the lung are serious, but there are many instances of re- 
covery even in cases where the laceration of the lung was probably 
extensive and accompanied a fracture that was in itself severe. 

Mention may be made in this connection of the case of recovery after 
complete transfixion of the chest from side to side by the shaft of a 

1 Diagnosis of Visceral Lesions, p. 213. 



316 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

chaise which measured five inches in circumference and penetrated for a 
length of twenty-one inches. The patient survived eleven years, and 
his thorax and the shaft are still preserved in the Museum of the Royal 
College of Surgeons, London. 

Treatment. — The indications for treatment are to reduce any displace- 
ment that threatens to produce a complication, or that causes pain, to 
immobilize the chest-wall, and to relieve or prevent pulmonary inflam- 
mation or congestion. 

Outward angular displacement may be corrected by pressure upon the 
projecting angle, and inward angular displacement may sometimes be 
corrected when the broken surfaces are still in contact, and the fracture 
is situated near the middle of the rib by pressing the sternum backward 
and thus springing the bone out. If the fragments have overridden this 
manoeuvre is worse than useless, for it can only increase the displace- 
ment. Malgaigne says the method was proposed by Lionet for use in 
those cases in which the pain is severe although the displacement is slight. 
Malgaigne himself used it successfully to relieve pain, and found by ex- 
periment upon the cadaver that he could thus partially reduce incom- 
plete fractures, but when he used much force the fracture was converted 
into a complete one. Relief may also be obtained by making the patient 
strain or draw full deep breaths. Ravaton relieved the pain and cor- 
rected the displacement in one case by suspending the patient upon two 
rods passed under his axillae. 

When the displacement was greater and one of the fragments was 
pressed inward Malgaigne ingeniously made use of the other to elevate 
it, pressing it in until the ends met and became locked together by the 
irregularities of their broken surfaces so that the elasticity of the second 
should serve to raise the first. He did this successfully in four cases 
and found that the pain was relieved by even a partial reduction, pro- 
bably because that was sufficient to disengage some point of bone that 
had been driven into the flesh. He found it advantageous to have the 
patient strain while the effort was making. 

For this elevation or removal of a depressed fragment by operation a 
number of methods have been proposed, but very few instances are 
known of the use of any of them. Malgaigne referring to only three 
cases, and Gurlt to only one additional. Malgaigne's cases are those of 
Soranus and Rossi. Of the former he says that a wound of the pleura 
by the bone being suspected, he exposed the rib by an incision, passed a 
strip of metal under it to protect the pleura, and excised and removed 
the splinters. Rossi says he once removed a fragment of a rib, and on 
another occasion raised the posterior extremity (portion ?) of the ninth 
rib by means of a lever introduced through an incision made below it. 
The account of Gurlt's case is equally scanty, a young surgeon is said 
to have resected, in opposition to Stromeyer's express commands, a por- 
tion of the bone in a case of non-penetrating fracture of the seventh and 
eleventh (seventh to eleventh ?) ribs with an unfortunate result. 

Malgaigne says that he never found it necessary to interfere in this 
manner, and that if the occasion arose he should prefer to use a hook 
like a tenaculum, passing it carefully behind the upper edge of the rib 




FRACTURES OF THE RIBS AND THEIR CARTILAGES. 317 

and along its inner surface, and then raising the bone with it. Agnew 
says this is easily done upon the cadaver. 

Immobilization of the chest is effected by surrounding it with a broad, 
snugly drawn bandage of muslin, flannel, or adhesive plaster. Some 
surgeons prefer to use strips of adhesive plaster two or three inches in 
breadth and only long enough to half encircle the chest, which they 
apply to the injured side letting each strip overlap one-third or one-fourth 
the breadth of the preceding one (fig. 160). 
Plaster of Paris has been used in a few instances, Fig. 1( 50. 

as have also sheets of felt or gutta percha moulded 
to the part and fastened on by straps of adhesive 
plaster. 

As the object of the bandage, whatever the 
material employed, is to immobilize the chest by 
suppressing thoracic respiration and making the 
diaphragm do the work it is essential that the 
abdomen should not be compressed, and therefore 
the bandage should be placed as high as pos- 
sible, and, if necessary, prevented from slipping 

7 , , , * 1 \ ill Adhesive plaster strips ap- 

downward by bands passing over the shoulders, piled for fracture of the ribs. 
The guide to the amount of pressure exerted by 

it is the comfort or discomfort of the patient. If the pain is increased 
or the breathing interfered w T ith, the bandage must be loosened or re- 
moved. As a matter of fact, the patient will himself immobilize his chest 
very satisfactorily by breathing carefully and superficially and by select- 
ing and keeping a favorable posture if the movements of the qhest are 
painful ; the bandage, therefore, is seldom more than a comparatively 
unimportant aid. Malgaigne preferred a bandage three or four inches 
wide and long enough to pass once and a half around the chest, and he 
did not place it lower than the ensiform appendix, believing it to be suf- 
ficient, whichever ribs might be broken, to restrain the movements of the 
middle ones. When a circular bandage cannot be borne he recommends 
that a long narrow strip of plaster should be carried from the anterior 
end of the seventh rib on the right side, for example, across the front of 
the chest, under the left arm and across the back to and over the right 
shoulder, thence again across the chest in front, and around the left side 
and back to end at the crest of the right ilium. This immobilizes the 
left side of the chest very effectually and leaves the right side free. He 
suggests that in addition the arm should be fixed to the side. 

The pressure of a bandage is useful also to prevent the spread of 
emphysema. This complication seldom requires any more active treat- 
ment, although scarifications are not infrequently made or the air drawn 
off through a trocar. If either method is used the instrument must be 
applied at a distance from the fracture, so as not to incur the risk of 
making it a compound one. The more dangerous variety of emphysema, 
that in which the air makes its way into the mediastinum and the inter- 
lobular tissue of the lung, is not amenable to operative treatment. 

In pneumothorax it may be desirable to draw T off the air through an 
aspirating needle or a canula in order to relieve the pressure, and if. 
blood accumulates within the pleural cavity in quantities sufficiently large 



die FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

to endanger life by interference with the action of the heart and either 
or both lungs it may become necessary to remove it by aspiration or in- 
cision, but the indications should be very plain before the surgeon decides 
to interfere in this manner, since the removal of the clotted blood and 
the relief of pressure may only lead to a return of the bleeding. Per- 
sistent internal hemorrhage can be treated only by indirect measures, 
because its source cannot be recognized, and if recognized, probably could 
not be reached. It has been found useful to constrict the thighs circu- 
larly at the groin with rubber tubing or a roller bandage just sufficiently 
to arrest the venous current ; this withdraws a considerable amount of 
blood temporarily from circulation and acts as a venesection. It some- 
times arrests bleeding instantly. 

When life is threatened by pulmonary engorgement with extreme dys- 
pnoea, blood should be taken from the arm immediately and freely, and 
the bleeding should be repeated if the symptoms reappear. The older 
records are full of cases showing the benefit of this practice, and among 
modern surgeons, Mr. Bryant recommends it unhesitatingly and forcibly. 
He says: "Bleed with no sparing hand. . . . When relief has 
been obtained arrest the flow immediately, as syncope can only do 
harm," and he supports the advice by the history of the following 
case. 1 

u In a case of severe injury to the chest, caused by the passage over 
it of the wheels of a heavily laden cart, that came under my care some 
time ago, fracture of five or six ribs and dislocation of the clavicle oc- 
curred, associated with collapse, intense dyspnoea, and haemoptysis ; I 
bled the. patient twice in twelve hours, and each time with immediate 
relief, the case going on to good recovery. In it the severe dyspnoea 
and venous congestion, the rapid and hard pulse that came on as soon as 
the collapse of the accident had passed away and the circulation had 
been restored, too surely pointed to an excessive engorgement of the 
lungs, and so if relief were not afforded, absolute suffocation would 
speedily ensue by the patient's own highly carbonized blood. At such 
a crisis, antimony, however beneficial in simpler cases, could not be 
trusted, as there was no time for it to take effect. Under these circum- 
stances bleeding was performed, and, as the blood flowed, life seemed 
gradually to return ; the laborious breathing became quiet and subdued; 
the deadened and congested eye bright and natural ; the pulse from being 
full and hard, softer and less bounding ; and the boy's feelings, released 
from the impression that death was nigh at hand, became more hopeful 
and resigned ; and, as a spectator, I felt such a hope was valid, and that 
success might crown our efforts. After the lapse of twelve hours, how- 
ever, the symptoms returned, and the repetition of the bleeding was 
followed by a repetition of all its benefits. The antimony then came in 
to complete the cure ; by the double venesection the pulmonary vessels 
had been relieved of their congestion, while the antimony, in acting upon 
the circulation, perfected the cure by preventing a return of the former 
threatening symptoms. The benefits arising from the treatment adopted 
in this case have such a lasting hold on my memory that I cannot too 

1 Practice of Surgery, 3d Am. ed., p. 573. 



FRACTURE OF THE COSTAL CARTILAGES. 319 

strongly recommend the practice thus pursued, and the more so, as I 
have seen it equally successful in other cases." 

Fracture of the Costal Cartilages . 

The first mention made of this lesion appears to have been by Zwinger 
in 1698, and it is not again referred to in medical literature until 1805, 
when Lobstein, at Strasbourg, and in 1806, Magendie, at Paris, each 
described it with cases. Additional observations were made by Del- 
pech, Sir Astley Cooper, and Yelpeau, and in 1841 Malgaigne 1 pub- 
lished a paper upon the subject which, six years afterwards, he repro- 
duced in part, in his book on fractures. Since then but little work has 
been done upon the subject, most writers contenting themselves with re- 
producing in substance Malgaigne's chapter. Gurlt collected more than 
thirty cases for the chapter upon it in his book on fractures, and Paulet, 2 
who appears not to have known of Gurlt's work, gives fourteen cases 
which he obtained by a partial search through French periodical litera- 
ture, only four of which are mentioned by Gurlt. The known instances 
of this lesion unaccompanied by other fractures are few in number, but 
still throw sufficient light upon the more important and practical questions 
that arise in connection with it. 

Fracture occurs much more frequently at or near the junction of the 
cartilage and rib than at any other point, and more frequently in the 
seventh and eighth ribs than in any other. The fracture may be double, 
and may involve several cartilages on one side or on both. Paulet gives 
two instances of "double fracture, both healed and without history, having 
been found in the dissecting room. As one of them is also the only 
known example of incomplete fracture, I reproduce the description. 
The observation is attributed to Duguet, but the reference is not given. 
"The eighth and ninth ribs on the left side are the seat of a double 
solution of continuity, the rupture following two parallel vertical lines. 
The first line on the eighth rib is three centimetres from the costo-chon- 
dral junction, and five centimetres on the ninth. The second is three 
centimetres from the first. Both fractures are complete upon the eighth 
cartilage, but only the outer one on the ninth." 

All the recorded fractures have been complete with the exception of 
this one case ; they have been perpendicular to the long axis of the 
cartilage, or very slightly oblique, and the surface has always been 
smooth, without serrations or splinters. 

It is probable that persons advanced in life are more liable to this 
fracture than the young, because of the calcification or ossification of the 
cartilages, but it has occurred in young men (17 years) and even in a 
child 7 years old. 

Displacement has been absent in a very few cases ; in most it takes 
place in the antero-posterior direction, and, in some, the fragments have 
overridden in the direction of the long axis of the rib. This latter form, 
probably, is possible only in the longer and more curved ribs, or when 

1 Bulletins de Therapeutique, 1841, p. 227. 

2 Diet. Encyclopedique, 1st Series, vol. xxi., art. Cotes, 1878. 



320 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

several adjoining ones are broken. The separation in either of these 
two directions may amount to as much as an inch, but is rarely so great. 
Either fragment may lie in front of the other, although the costal frag- 
ment projects more frequently than the sternal one ; the displacement, 
however, appears to depend entirely upon the direction of the fracturing 
force and upon the position occupied by the patient, and consequently to 
follow no definite laws. 

No instance of a compound fracture of a costal cartilage is on record, 
and the complications are less frequent and, as a rule, less serious than 
those accompanying fractures of the ribs. In some cases where the 
violence has been extreme and many cartilages have been broken fatal 
injury has been done at the same time to the heart or great vessels, but 
not by the penetration of one of the fragments ; the viscera are crushed 
or torn by the continued action of the force after the wall of the chest 
has yielded under it. In a case reported by MacLeod a bullet struck 
the front of a soldier's cuirass and bent it in, breaking the cartilages of 
the fifth, sixth, and seventh ribs close to the sternum. The man went 
to the rear, walked about for two hours, was then taken with violent 
pain in the region of the heart, and died three days afterwards. The 
left ventricle was found ruptured. 

Hernia of the lung has been observed in three cases, one after frac- 
ture of the third and fourth cartilages and rupture of the intercostal 
muscles by the fall of a heavy weight, the second, a double one, after 
fracture or diastasis due to paroxysms of coughing, and the third, ob- 
served by Legros Clark 1 after a blow received from the shaft of some 
•vehicle. In this one the cartilage of the second rib" was driven in, 
creating a gap through which a tumor as large as the first appeared at 
each inspiration and disappeared at each expiration, leaving a depres- 
sion capable of containing at least two ounces of liquid. Recovery in 
three weeks, the gap persisting but "evidently occupied by some 
plastic deposit." 

In seven cases the fracture has been produced by muscular action, 
either an excessive effort, as to avoid a fall or to throw a heavy object, 
or coughing or sneezing. Thus Broca 2 reported the case of a porter at 
the market who having placed a sack of peas upon his shoulder asked a 
comrade to add another to it. The latter threw the second sack heavily 
upon him, and in the effort to avoid a fall under the weight he fractured 
the cartilages of the sixth, seventh, and eighth ribs on the right side at 
points seven or eight centimetres from the median line. 

Fractures by external violence may be direct or indirect ; in many 
cases it is difficult, sometimes impossible, to recognize the mechanism. 
Gurlt thinks the indirect fractures take place at or near the costo-chon- 
dral junction, the force acting upon the rib itself in such manner as to 
spring its anterior end outwards, while in the direct fractures the force 
is exerted upon a restricted area of the cartilage itself, as in a fall upon 
the edge of a tub or step, the blow of a fist, the kick of a horse. The 
following cases will serve as illustrations. 



1 Loc. cit., p. 206. 

2 Quoted by Paulet, loc. cit., p. 83. 



FRACTURE OF THE COSTAL CARTILAGES. 321 

1. A man 46 years old 1 was caught in a mill and crushed between 
the beam and the wall. The ends of all the ribs on both sides projected 
distinctly at their junction with the cartilages, and "his chest was to 
the feeling like a dead body where the thorax had been opened and the 
sternum left loose under the integuments. The outer end of the left 
clavicle was dislocated. The patient was pale, breathless, and covered 
with cold perspiration." Venesection, bandage about the chest, shoul- 
ders retracted by a figure-of-eight bandage. Complete recovery in 
twenty-five days, the ribs still projecting on the right side. 

2. A mason fell sixty feet 2 and died in a few hours. Besides an 
injury to the head and fracture of the ribs there was found a consider- 
able depression of the anterior lower part of the breast on the right side 
due to fracture of the cartilages of the sixth, seventh, and eighth ribs 
with overriding of the fragments for about an inch, which could not be 
corrected even at the autopsy. 

3. A man was thrown from and stepped on by his horse, 3 the hoof 
resting on the upper and anterior portion of the chest. There was some 
dyspnoea, local pain, but no ecchymosis. The fourth cartilage was 
forced backward and downward, the anterior end of the corresponding 
rib projected. At each deep inspiration the cartilage returned to its 
place, but the displacement recurred during expiration. 

The symptoms are local pain and deformity. Crepitation and abnor- 
mal mobility are not often recognizable, but if displacement is present it 
can usually be made out by following the outline of the rib and cartilage 
with the finger and by observing that it can be increased or diminished 
by pressure upon one or the other fragment. It may be easy in some 
cases to say whether the fracture involves the rib or the cartilage, and 
in others whether it is a fracture of the cartilage or a dislocation of its 
sternal end, but the question has no practical importance. In the first 
case examination of the projecting end of the posterior (vertebral) frag- 
ment with an acupuncture needle may show whether it is composed of 
bone or cartilage ; and in the second the outline of the sternum will 
show a small projection if there is a fracture close to it, and a cup-like 
depression if the injury is a dislocation. 

The prognosis, independent of complications, is favorable, and the 
fracture may be expected to unite in three or four weeks. Our know- 
ledge of the mode of repair has been obtained partly by experimenta- 
tion and partly by examination of specimens. When the fragments 
remain end to end and the fractured surfaces are more or less completely 
in contact, a fibrous band unites them, and the union is strengthened by 
an external ring of spongy bone. In a specimen obtained by Basserau 4 
and examined microscopically by Malassez it was found that the cen- 
tral band was partly cartilaginous, and it is asserted that in other speci- 
mens points of ossification have been found. 

When the fragments override, they take, so far at least as the broken 
ends are concerned, little or no part in the repair. Union is accom- 

1 Chas. Bell, Surgical Observation, London, 1817, p. 171. 

2 Magendie. Bibliotbeque Medicale, 1806, p. 82. (Grurlt.) 

3 Bouisson. Quoted by Grurlt. 

4 Paulet, loc. cit., p. 88. 
21 



322 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

plished by an intermediate band which is at first fibrous and afterwards 
becomes bony (fig. 161) ; or if the fragments are in contact, the new 
bone forms on the sides and the ends (fig. 162), and in both cases it 



Fig. 161. 



Fig. 162. 





Eepair of fracture of a costal cartilage. (Gurlt.) 



Repair of fracture of a costal cartilage. 



envelops the pieces more or less completely like a ring. This ring 
originates apparently in the perichondrium, and its ossification is the 
final result of the formative irritation created by the traumatism, and is 
analogous to the ossification seen so constantly not only in cartilage 
which would normally be transformed into bone, but also in others, such 
as that of the larynx, whose normal evolution does not include that 
change. 

The treatment is similar to that of fracture of the ribs ; reduction of 
displacement if necessary and possible, and immobilization. The former 
must be accomplished, if at all, by pressure, by placing the patient upon 
the opposite side or upon his back, by drawing the shoulders back, or 
by deep inspirations ; the latter by a body bandage, strips of adhesive 
plaster, or, following Malgaigne's example, by a hernial truss so placed 
as to restrain the fragment that tends to project. 



FRACTURES OF THE CLAVICLE 



323 



CHAPTER XIX. 

FRACTURES OF THE CLAVICLE. 

The clavicle is more frequently broken than any other bone in the body, 
the radius perhaps excepted, as a reference to the tables of statistics in 
Chapter I. will indicate, and as the following table compiled from a simi- 
lar source as the others and with more detail will prove. Statistics 
composed only of cases treated in hospital give a frequency that is rela- 
tively much less, because many of the cases are treated as " out-patients." 
Thus the statistics of the Paris hospitals for four years, 1861-64, con- 
tained 7687 fractures, of which those of the leg formed 15 per cent., of 
the ribs 13 per cent., of the radius 9.8 per cent., and of the clavicle 7.9 
per cent. 1 

Fractures of the Bones of the Upper Extremity treated at the Middlesex 
Hospital during a period of Sixteen Years ending Jane 30, 1807. 2 





Age. 


Total. 




to 5. 5 to 15. 


15 to 30. 


30 to 45. 


45 to 60. 


Above 60 






M. 

5 


F. 


M. 


F. 


1 


F. M. 



1 11 


F. 

6 


M. 

7 


F. 


M. 
1 


F. 
1 


M. 
28 


F. 
11 


M. F. 


Scapula . 


3 3 


39 


Clavicle . 


176 


171 


84 


47 


56 


26 


67 


33 


51 


33 


18 


10 


452 


320 


772 


A v ( Upper end . 

| g \ Shaft . 

►3 m ( Lower end . 


1 


4 


7 


2 


5 


. . . 


11 


5 


8 


4 


5 


8 


37 


23 


60 


39 


22 


42 


17 


27 


18 


25 


16 


11 


16 


6 


15 


150 


104 


254 


8 


4 


46 


3 


14 


2 


o 


2 


5 


1 


1 


1 


76 


13 


89 


Olecranon 


1 




t 


2 


23 


3 


14 


5 


8 


4 


4 


5 


57 


19 


76 


Ulna exckid. olecran. 


8 


7 


19 


1 


7 


6 


19 


10 


13 


10 


2 


5 


68 


39 


107 


Radius alone . 


62 


64 


92 


19 


78 


45 75 


57 


45 


123 


21 


87 


373 


395 


768 


Ulna and radius 


20 


17 


71 


11 


15 


7 


8 


9 


9 


12 


4 


8 


127 


64 


191 


Carpal bones . 
Metacarpal bones . 


























1 
141 


"27 


1 


1 


"i 


I'io 


1 


62 


9 


50 


13 


15 


3 


3 




168 


Phalanges 


3 


3 


, 44 


7 


47 


8 32 


13 


24 


5 


4 


1 


144 


36 


180 


Total . 


324 


295 425 
I 


no 


335 


125 315 

! 


169 


196 


211 


60 


u, 


1654 


1051 


2705 



It also shows that in nearly half the cases the patients were not more 
than five years old, that up to this age the frequency is about the same 
in the two sexes, and that afterwards the injury is more common in 
males than in females. Gurlt's Berlin statistics make the frequency 
after the age of ten years nine times as great in males as in females, but 
his statistics include only 113 cases. There are nine or ten recorded 
cases of intra-uterine fracture by external violence. 



1 Diet. Encyelopedique, art. Clavicle, p. 677. 

2 Holmes's System of Surgery, Am. ed., vol. i. p. 



845. 



324 FRACTURES OF THE CLAVICLE. 

Pathology. — It has been found convenient by most modern authors for 
the purposes of study and description to divide the fractures into three 
groups, according as they occupy the inner, middle, or outer thirds of 
the bone. The average length of the clavicle is six inches, and this 
division into thirds of about two inches each corresponds to anatomical 
differences of considerable clinical importance. To the flattened outer 
third are attached the trapezius and deltoid muscles and the strong 
coraco-clavicular ligament binding it to the coracoid process, the inner 
fasciculus of which, known as the coracoid ligament, marks the inner 
limit of this portion, and can sometimes be readily felt upon the living 
body. The dividing line between the inner and middle thirds is not so 
definitely marked anatomically, it corresponds approximately to the 
point where the clavicle crosses the lower or outer edge of the first rib. 
The inner third is attached to the sternum by the sterno-clavicular liga- 
ments ; and to the cartilage of the first rib by the costoclavicular or 
rhomboid ligament. To its upper border is attached the sternocleido- 
mastoid muscle, to its lower the pectoralis major. 

Since the outer third is broadly attached by ligaments to the scapula 
it is apparent that after fracture of the bone in the inner or middle third 
the outer fragment will not be able to change its relations to the scapula 
materially, and that its displacement therefore will be governed by the 
change of position of the latter, by its sinking inward and forward to the 
side of the chest in consequence of the loss of its anterior support. 

The outer portion of the middle third is by far the most common seat 
of fracture, apparently because this is the smallest and most sharply 
curved part of the bone and must therefore yield to indirect violence 
more readily than any other part. Hamilton 1 says that of 157 cases, 
exclusive of gunshot fractures, 127 were in the middle third; and exclud- 
ing the partial fractures, the fracture was nearly always near the outer 
end of this third ;. 4 were in the inner third, 17 in the outer third. He 
adds, further, that he has seen only one case of complete fracture in the 
adult produced clearly by a counter stroke that was not near the outer 
end of the middle third. Of 140 cases treated in the New York Hospi- 
tal, 2 3 were near the sternal end, 4 at the junction of the inner and mid- 
dle thirds, 43 in the middle third, 67 at the junction of the middle and 
outer thirds, and 23 near the acromial end. Of 61 cases observed by 
Hurel, 3 exclusive of double fractures, 44 were of the middle third, 14 of 
the outer third, and only 3 of the inner third; three-fourths of those of 
the middle third were situated at or within half an inch of its outer end. 

The fracture, like others, may be partial or complete, single or mul- 
tiple, simple or compound ; the most frequent form is simple complete 
fracture. Compound fracture is so rare that Gurlt says he could find 
only four examples of it, and Hamilton, who gives the same four cases, 
says he had never met with an example. A case has recently been 
under my care at Bellevue Hospital (1881) ; an Italian laborer was 
struck by a falling stone upon the shoulder and sustained a fracture of 
the right clavicle at a point nearly two inches from the sternal end of 

1 Fractures and Dislocations, 6th ed., p. 195. 

2 Lente, N. Y. Journal of Med., 1851, vol. ii. p. 159. 

2 Les Fractures de la Clavicule, These de Paris, 1867, p. 48. 



FRACTURES OF THE CLAVICLE. 



325 



the bone. The line of fracture was oblique from above downward and 
inward. A large ragged wound extended backward across the clavicle 
and shoulder, in which some of the divided fibres of the trapezius could 
be seen. The outer end of the inner fragment was directed sharply up- 
ward, the outer fragment lying below and a little distance from it. The 
wound healed almost entirely in about six weeks, but when last seen 
there was still a sinus over the end of the inner fragment from which 
pus flowed freely and through which a probe could be passed to the bone. 
Incomplete or partial fracture is, according to Hamilton, who has given 
much attention to this variety, very common. He thinks that 3-1 of the 
157 fractures of the clavicle recorded by him 1 were partial fractures, 
and says that at least eleven of these were immediately and sponta- 
neously restored to their natural axes. The symptoms accepted for this 
diagnosis are the history of a fall upon the shoulder, or at least indirect 
violence, the youth of the patient, a swelling upon the upper surface 
and front or rear border of the middle third of the bone appearing with- 
in two or three days after the accident, possibly a change in the axis of 
the bone, and possibly ability to straighten it with slight crepitus. 

Fig. 163. 




Oblique fracture of the clavicle. 

1. Complete Fractures of the Middle Third may be oblique or trans- 
verse, the former variety being found most commonly in adults, the 
latter in children. The line of an oblique fracture usually runs inward 
and downward or backward, but may take any other direction and may 
be nearly transverse, or extremely oblique (fig. 163), or practically 
longitudinal as in a case observed by Chassaignac and mentioned by 
Polaillon 2 in which the fracture ran from the centre of the acromial end 
to a point just external to the sterno-clavicular articulation, dividing the 
bone into two longitudinal halves. Transverse fractures are thought to 
always present an irregular or toothed surface, a condition opposing 
displacement ; and in consequence of this fact and of the other that this 
variety is moro commonly found in children, it often happens that the 
periosteum is not torn. Multiple and comminuted fractures are rare. 
Hamilton has seen only six cases of the- latter, exclusive of gunshot frac- 
tures, all occupying the middle third. I have seen one such, also of the 
middle third, with much displacement of the fragments and threatening 
of perforation by the sharp end of one of them, which was, however, 
prevented. When the fracture is multiple or double, the intermediate 
fragment is likely to occupy a very irregular position. 



1 Fractures and Dislocations, 6th ed., p. 90. 

2 Diet. Encyclopedique, Art. Clavicle, p. 682. 



326 



FRACTURES OF THE CLAVICLE. 



The displacements which are the most common are produced bj the 
falling forward, downward, and inward of the shoulder, the consequence 
of the loss of the support normally furnished by the clavicle, and depend 
somewhat upon the direction of the line of fracture. The commonest 
form is that in which the sternal fragment is drawn upward by the sterno- 
cleido-mastoid muscle or pushed upward by the other fragment which 
is displaced inward along the under or anterior surface of the other and 
has at the same time changed its direction somewhat by the sinking of 
its acromial end. The shortening may be very notable, nearly one- third 
of the entire length of the bone in a specimen mentioned by Malgaigne. 
Another form is found where the line of fracture is such that the frag- 
ments do not readily leave each other, and the broken ends are displaced 
together upward and backward by the falling in of the shoulder so that 
the bone forms an angle at the seat of fracture. In some exceptional 
cases the outer fragment has lain upon the upper or posterior surface of 
the inner fragment. Malgaigne 1 says this variety was mentioned by 
Hippocrates, and that he himself saw one, but only one, example of it. 
Under these circumstances the sternal fragment is held down instead of 
being pushed up by the other one, and the displacement is mainly in the 
direction of the latter, the inner end of which is turned upward forming 
a projection at the seat of fracture. Figs. 164 and 165 represent ex- 

Fig. 164. 




Fracture of the clavicle. Union with extreme displacement. 
Fie. 165. 




Fracture of the clavicle. 



treme angular displacement after fracture, in one case in the outer third, 
and in the other near the inner limit of the middle third. 

In transverse fractures the broken surfaces seldom leave each other, 
and the only displacements possible are in thickness and direction, the 
lateral and angular. The lateral is the one usually seen, the angle 
being directed, for reasons that have been already stated, upward and 
backward. 

The most common and persistent cause of these displacements is un- 
doubtedly the tendency of the scapula and shoulder to fall forward and 
inward upon the chest, but it is aided largely in the first place by the 



i Loc. cit., p. 468. 



FKACTURES OF THE CLAVICLE. 327 

fracturing force which continues to act after the bone has yielded to it. 
Thus, in a fall upon the shoulder or the outstretched hand, the clavicle 
breaks by the exaggeration of its normal curves, and as the direction of 
the line of fracture is usually downward and inward the outer fragment 
is forced inward on the under side of the other and necessarily turns the 
outer end of the latter upward. In like manner, if the fracture is by 
direct violence acting downward and backward the force, continuing to 
act after the bone has broken, depresses the broken ends in the same 
direction. 

2. Fractures of the Outer Third. — This variety is next in frequency 
to the preceding, and may be produced by direct or indirect violence. 
The direction of the line of fracture is more commonly transverse than 
oblique. The degree of displacement varies greatly in different cases, 
being very notable in some and slight or entirely absent in others. R. 
W. Smith, of Dublin, attributed these differences to the position of the 
fracture, according as it lies within the area of the attachment of the 
coraco-clavicular ligament, or on the outer side of it, and he maintained 
that displacement was slight or absent in the former case, because the 
fragments were retained in contact by the untorn ligament that was 
attached to both, and might be great in the latter, because then the outer 
fragment was uncontrolled by fixed bands. Gordon 1 called in question 
the accuracy of both the explanation and the statements, claiming not 
only that displacement might be very marked when the fracture lay 
within the region of the ligament, but even that the majority of the 
fractures lay within this portion. Gurlt accepts Gordon's views, so far 
at least as to admit that displacement may, or may not be present, and 
supports them by reference to specimens. He further criticizes Smith's 
estimate of the distance to which the attachment of the ligament extends 
outwardly, and gives it a much wider range, one that includes all but 
about the outer inch of this division of the bone. This anatomical fact 

Fig. 166. 



-. J* 




Fracture of clavicle, outer third. Extreme angular displacement. (R. W. Smith.) 

makes one of Smith's own specimens support the statements of his critics 
(fig. 166). When displacement exists it is usually an angular one, the 
apex of the angle being directed backward. In some specimens 2 bony 

1 Dublin Journal Med. Sci., 1859, vol. ii. p. 478. 

2 Smith, in Dublin Journal Med. Sci., 1842, p. 47S, and Fractures in the Vicinity 
of Joints, p. 212. 



328 FRACTURES OF THE CLAVICLE. 

union is shown to have taken place between the clavicle and the scapula, 
presumably by ossification of the coraco-clavicular ligament. It is in 
the form of a prop extending from the under side of the clavicle to the 
base of the coracoid process, and sometimes to the notch of the scapula, 
and usually convex posteriorly. 

When the fracture is external to the trapezoid ligament, that is, when 
it lies within the outer inch of the bone, displacement is the rule, the 
outer fragment turning forward and inward until its axis is at right 
angles with that of the inner fragment (fig. 167) ; sometimes its broken 

Fig. 167. 




Fracture of clavicle, outer third. Union with displacement of outer fragment. (E. W. Smith.) 

surface lies against the anterior border of the inner one, and sometimes 
the outer fragment lies under the inner one. Malgaigne describes a case 
in which, after fracture within half an inch of the articular surface, the 
inner fragment was elevated an inch above the other, and there was 
shortening of nearly half an inch ; the appearance, in short, was that of 
a dislocation upward of the acromial end of the clavicle. An instance 
of extreme deformity after fracture at three-fourths of an inch from the 
acromial end is described and pictured by Smith. " The supra-clavi- 
cular space was diminished in a remarkable manner by the elevation of 
the clavicle which formed a very acute angle with the posterior border 
of the sterno-mastoid muscle. The shoulder was drawn forwards and 
inwards, the distance between the sterno-clavicular articulation and the 
extremity of the acromion being nearly an inch less than upon the op- 
posite side." The outer end of the clavicle is raised high above the 
acromion. The relations of the fragments to each other are shown in 
figure 167. 

3. Fractures of the Inner Third. — The older division, which was into 
fractures of the body and fractures of the outer end, took no special 
notice of this variety which received its first separate description from 
Malgaigne. It is the least common of the three ; Delens 1 who wrote 
the first formal article upon the subject collected 28 cases, to which 
Polaillon, two years later, added 3. The fracture may occupy any point 
in the division, and is more often oblique than transverse. It was 
asserted at first that displacement did not occur if the fracture was 
within the region of the attachment of the costo-clavicular ligament, but 
the contrary has since been proved ; displacement may take place in any 

1 Archives Generales de Med., 1873, vol. i. p. 529. 



FRACTURES OF THE CLAVICLE. 329 

direction, but the commonest one is downward and forward of the inner 
end of the outer fragment, or of the adjoining ends of both fragments 
if they do not separate from each other. Polaillon attributes the princi- 
pal part in the production of this displacement to the action of the pec- 
toral and deltoid muscles upon the outer fragment, and finds support for 
his opinion in the fact that this displacement has always been observed 
after fracture by muscular action ; and as in this variety the fracture is 
usually near the inner articular surface, in a region, that is, where dis- 
placement after fracture by other causes is slight or absent, the argu- 
ment is not without weight although the obliquity of the line of fracture 
in such cases as that represented in figure 168 cannot be entirely foreign 

Fig. 168. 




Fracture of the clavicle, inner third. (Gurlt.) 

to the direction and degree of the displacement. When the fracture is 
transverse the lateral displacement may be slight or entirely absent and 
the periosteum may remain untorn. Longitudinal fracture with commi- 
nution was seen in one case, and Hamilton reports another in which the 
line ran from the articulation upward and outward for one and a half 
inches. The fragments overlapped three fourths of an inch and were 
firmly united. In two cases the end of the outer fragment lay under- 
neath the inner one and both were directed upward and backward. The 
outer end of the inner fragment is acted upon more strongly by the- 
sterno-cleido muscle than by any other, the effect of which is to draw it 
upward, and this effect is increased by the pressure of the outer frag- 
ment when that is forced in front of and below the other, so that when- 
ever the two fractured surfaces leave each other the inner fragment is 
likely to incline upward. 

The opinion has been held in a few cases that the injury was a sepa- 
ration of the epiphysis rather than a fracture, but there appears to be no 
warrant for the view, since the epiphysis is very thin, not more than a 
scale, its point of ossification does not appear until the twentieth year, 
and consolidation is complete within a year or two thereafter. 

3Iultiple Fractures. — But few cases are recorded in which the bone 
has been broken in two or more places ; in some the fracture was by 
direct, in others by indirect, violence. Both fractures have been found 
in the middle third, but more commonly they occupy different thirds. 
When one fracture has been in the acromial, and the other in the inner 
or middle third, the intermediate piece has not shown much displacement, 
and each fracture has followed the usual course of a single one ; but 
when the fractures have been within or close to the limits of the middle 



330 FRACTURES OF THE CLAVICLE. 

third, the displacement has been very notable, and, as in the following 
case briefly reported by Malgaigne, 1 irreducible. 

A little girl suffered a double fracture of the clavicle ; the inter- 
mediate piece, which was about two centimetres long, was turned so as 
to lie vertically between the others, and all the efforts made by Mal- 
gaigne and Guersant failed to correct the position. Union took place, 
but with notable deformity. 

Complications of fracture of the clavicle consist in injuries to the ves- 
sels, nerves, and lungs, and are exceedingly rare, excluding gunshot 
wounds in which the complications are produced by the ball and not by 
the fractured bone. Although the subclavian artery is in intimate rela- 
tions with the clavicle, I find no recorded case of its injury as a com- 
plication of the fracture of this bone. Dupuytren speaks in a lecture of 
having seen two or three cases of aneurism following fracture of the 
clavicle, and Jacquemiei 2 gives a case observed by Blandin, of an aneur- 
ism of the acromial branch of the acromial-thoracic artery following 
fracture by direct violence. Gurlt refers to a case mentioned by Erich- 
sen, as a probable wound of the subclavian artery, but he takes his ac- 
count from a German translation, and a reference to the original work 3 
shows that it was the vein and not the artery that was thought to be 
wounded. 

A few cases are reported of injury to the subclavian or internal jugu- 
lar vein, in some of which the diagnosis was verified by autopsy. In 
the museum of St. George's Hospital 4 is a specimen in which the frac- 
tured end of the bone was driven through the internal jugular vein. 
The patient, a youth aged 23, while standing under a tree during a 
thunder storm was struck by a falling branch and died immediately. 

Of the clinical cases that of Sir Robert Peel is perhaps the best 
known. There was a "comminuted fracture of the left clavicle, below 
which a swelling as large as the hand could cover, and which pulsated 
synchronously with the contractions of the auricles of the heart, formed. 
It was evidently the result of a wound of some large vein, probably the 
subclavian, by the broken end of the bone." There were severe asso- 
ciated injuries, and the patient died. 

A case has been recently reported in which the patient, 5 a man 59 
years old, broke the right clavicle in the middle third by a fall upon the 
shoulder. A large swelling appeared promptly in the supra-clavicular 
region and extended to the parotid ; it did not pulsate, and had a slight 
intermittent murmur isochronous with the pulse . The arm was paralyzed, 
and the radial pulse lost. On the following day the pain was less, and 
the pulse had reappeared. An incision was made, an enormous quan- 
tity of blood escaped, and the patient died at once in consequence of the 
entrance of air into the vein. The fracture was very oblique, from with- 
out inwards and backwards, and the vein was torn completely across by 
the outer fragment. The artery and nerves were not injured. 

1 Loc. cit., p. 466. 

2 Fractures de la Clavicule, These d'Agregation, Paris, 1844. 

3 Eriolisen, Science and Art of Surgery, Am. ecL, 1873, vol. i. p. 348. 

4 British Medical Journal, 1873, vol. ii. p. 82. 

5 Progres Medical, 1882, No. 16. 



FRACTURES OF THE CLAVICLE. 331 

Erichsen 1 reported a case of supposed compression of the subclavian 
vein by one of the small fragments of a comminuted fracture produced 
by direct violence, but admits that the autopsy showed no signs of such 
compression, and that the only reason for suspecting it was the gangrene 
of the arm which appeared on the second day and led to amputation and 
death by pyaemia. He refers in passing to a case of laceration of the 
subclavian vein that had been brought to the University Hospital a few 
years before, but gives no details. 

Finally, Annandale 2 once felt justified in cutting down upon a simple 
comminuted fracture to remove a fragment which he feared was pressing 
upon the subclavian vein, and might cause it to ulcerate. The patient 
died in consequence, it is said, of associated head injuries. 

Gurlt gives four cases of probable injury to the brachial plexus by the 
broken clavicle, but adds that in the absence of direct examination of the 
parts we must remain in doubt as to the exact character of the lesion and 
of the mechanism by which it was produced. Another case is reported 
by Mercier, 3 fracture of the middle third with immediate and persistent 
paralysis of the arm. The accident was caused by the slipping of a 
large cannon, the patient, a sailor, being caught between the muzzle and 
the side of the ship. Mercier thought the inner end of the outer frag- 
ment had torn the nerve trunks. In three of Gurlt's four cases the para- 
lysis and numbness disappeared wholly or in part under treatment. In 
the remaining one it persisted. 

Injury to the lung, as evidenced by emphysema, has been recorded in 
five cases where this symptom seemed to be demonstrative, and in two 
others in which it is much more likely that the emphysema was due to 
the introduction of air through a wound of the soft parts. 

The first five cases are those of Yi^arous, Velpeau, Huguier, Ruble, 
and Mercier. All except the fourth, Ruhle's, are described with all the 
details that are obtainable in the thesis of Mercier above mentioned. 
Ruhle's is mentioned by Bardeleben 4 in a foot-note, as an oral communi- 
cation by Prof. Rlihle to the eifect that he had known after fracture of the 
clavicle and displacement inward of the outer fragment a notable emphy- 
sema to appear immediately without fracture of the rib. Velpeau 5 says 
of his case only that " the outer fragment had been pushed so far by 
the fracturing cause that an enormous emphysema of the entire trunk 
ensued," and that he could recognize no fracture of the ribs. The pa- 
tient appears to have survived. In Huguier's 6 case the clavicle was 
broken by a fall from a height of twenty feet ; the patient was brought 
to the Hopital Beaujon presenting a considerable emphysema of all the 
left side of the chest in front and behind, without fracture of the ribs or 
external wound. There was haemoptysis the next day. 

VigarousV patient had his clavicle broken by a blow from the shaft 
of his wagon while trying to stop his horses which had taken fright at a 

1 British Med. Journ., 1873, vol. i. p. 637. 

2 Brit. Med. Journal, 1873, vol. ii p. 82. 

3 Des Complications des Fractures de la Clavicule, These de Paris, 1881. 

4 Lehrbuch der Chirurgie, 7th ed., 2d vol. p. 405. 

5 Anatomie des Regions. 6 Gaz. des Hopitaux, 1847. 
7 (Euvres de Chirurgie, Montpellier. 



332 FRACTURES OF THE CLAVICLE. 

wolf in the road. His breast, head, and neck swelled immediately, and 
there was so much dyspnoea that he was obliged to lie upon the ground. 
He remained thus for three hours and was then seen by the surgeon, 
who found the chest and neck two and a half times as large as normal, 
and says he had never before seen anything so hideous, so monstrous. 
The patient was bled as often as it was thought he could bear it, band- 
ages were applied, and a great variety of liniments and decoctions 
rubbed over him, but without improvement. Narcotics failed to give 
him rest or to quiet his cough, the pulse became frequent and small, the 
respiration hurried, and the patient was evidently approaching his end. 
The emphysema had spread to the arm and hand, the eyelids were enor- 
mous, and the lips three inches thick and everted. The family then 
assented to the proposition that had been made a few days before, and 
the surgeon made an incision three inches long through the skin over the 
fracture. In a week the emphysema had entirely disappeared, and the 
patient recovered. 

In Mercier's case the patient, a woman 60 years old, was brought to 
the Hopital de la Charity, Paris, service of Despres, on the 30th May, 
1881, with a fracture of the right clavicle at the junction of the outer 
and middle thirds caused a week before by the fall of a shutter. The 
emphysema occupied the upper portion of the body but not the head ; 
the patient suffered somewhat with dyspnoea but made no complaint of 
pain and would not wear any dressing. She said the dyspnoea was 
greatest during the first three days following the accident. The physi- 
cal signs of pneumothorax were not present ; there was no fever, no 
cough, no haemoptysis, no external wound. The emphysema disappeared 
in three weeks, and the patient left the hospital June 22d, the fracture 
not yet united. 

The anatomical demonstration of the immediate agency is lacking in 
all these cases, but the notes in all but one show that the surgeons were 
mindful of the possibility that a fracture of a rib might coexist and 
might have been the cause of the wound in the lung, and that they were 
unable to detect such a complication. In most of them, too, mention is 
made of the depression of the outer fragment, and as the relations of the 
clavicle to the upper portion of the thoracic cavity are such that it is 
not difficult to admit the possibility of a wound of the apex of the lung 
by the broken bone, I think the clinical evidence may be accepted as 
sufficient. 

Etiology. — The clavicle may be broken by muscular action, by direct 
violence, or by indirect violence. Gurlt, writing in 1864, had collected 
twenty cases of fracture by muscular action, and the list has been in- 
creased somewhat subsequently by the experience and researches of 
Delens. In the paper above referred to (Archives Generates, 1873) 
he collected eight cases of fracture of the inner end of the bone, and in 
a subsequent one (Arch. Gen., 1875, i. p. 257) he collected nineteen 
cases of fracture of the body of the bone in this manner, three of which 
were personal. Gurlt asserts that this variety of fracture is found most 
frequently in the middle third of the bone, but his cases are so lacking 
in details that only a few of them can be used to determine this point. 

The efforts by which the fractures w T ere caused were various : lifting 



FRACTURES OF THE CLAVICLE. 333 

a heavy weight ; striking with the hand, a whip or racket ; making a 
vigorous effort that involved the contraction of many muscles, as in 
Legros Clark's case of a lad who, while swinging by the feet from a 
trapeze, tried to raise himself so as to seize the bar with his hands ; the 
clavicle broke in its inner third during the effort. It is probable that 
the clavicular fibres of the deltoid and pectoralis major are the most 
efficient agents in producing this fracture, since their contraction tends 
to draw the inner portion of the clavicle downward and outward toward 
the humerus when the arm is fixed, a direction that corresponds, as has 
been already said, with the displacement found after fracture in the 
inner third. 

Closely allied to these cases are those in which the fracture has been 
produced by a blow or other force acting at the hand ; thus, an old 
woman broke her clavicle by closing the door of a wardrobe forcibly, 
and a lunatic at Bice're broke his by striking violently with a heavy 
stick against some iron bars. 

In a very few of the cases the fracture has been produced by two 
efforts, or a blow and an effort, separated by a longer or shorter interval ; 
the patient feels pain at some point in the clavicle after a fall or a blow 
or an effort, which persists perhaps, but is not severe and does not inter- 
fere with the use of the arm ; and then in a few days, after another 
violence or effort, the bone breaks. If the second violence were suffi- 
cient in itself to account for the fracture, the first one might be regarded 
as a mere coincidence, but it has generally been less than the first. 

Direct fractures are produced by very various causes, and may occur 
at any part of the bone, but most frequently in the middle and outer 
thirds. The commonest form of violence is a blow falling upon the cen- 
tre of the bone in a direction that is backward and downward. 

Indirect fractures, which constitute the great majority, are most fre- 
quently produced by a fall upon the hand, elbow, or shoulder, the arm 
being extended and the muscles rigid. In a few cases the fracture has 
been caused by the sudden depression of the shoulder, by which the 
clavicle was bent over the first rib. Malgaigne 1 reports one : an incom- 
plete fracture at the middle of the bone due to the slipping of a burden 
from the shoulder to the arm ; and Polaillon 2 another : a man who held 
the end of a lever which was to receive part of the weight of a heavy 
stone, the stone slipped suddenly upon the lever and drew the arm 
which held it downward. The man heard a snap and felt pain in the 
shoulder ; the clavicle was broken in its middle third. 

The clavicle has been broken in a number of cases during intra-uterine 
life by external violence, and occasionally by the midwife or obstetrician 
during parturition. 

jSi mid tan eons fracture of both clavicles is, as might be expected, a 
rare accident. Malgaigne collected six cases, one of which came under 
his own observation ; Gurlt added fourteen to this list, and Hamilton two ; 
Hurel's thesis contains two others, and Polaillon says he found seven 
reported in French journals and observed one himself. Of these last 
eight I can identify four as found also in the other lists, leaving a total 

1 Loc. cit., p. 463. 2 Loc. cit., p. 679. 



334 FRACTURES OF THE CLAVICLE. 

of twenty-eight cases, in eight of which, however, most details are lack- 
ing. In Hamilton's two cases the patients were young boys ; one of 
Gurlt's was a five year old girl and another was a woman ; all the rest 
appear to have been men. Three of the fractures in Hamilton's two 
cases were incomplete. In position, symptoms, and mode of production 
these double fractures do not differ materially from single ones. Of the 
twenty cases in which the mode of production is given, it was in eight 
a force acting upon both shoulders in the transverse diameter of the 
body, and in three it was the caving in of an embankment, the mechan- 
ism probably being the same. In two it w T as by direct violence ; in one 
of them a wounded soldier during Napoleon's retreat from Russia was 
set upon by the Cossacks and pounded with the butts of their guns ; in 
the other a groom was kicked by a horse, each hoof breaking a clavicle. 
The others were indirect or combinations of direct and indirect fractures. 
In one case one clavicle was broken by direct violence, the blow threw 
the man to the ground and caused indirect fracture of the other ; in 
another the patient fell and broke one clavicle, and w T hile lying on 
the ground was run over by a wagon which broke the other by direct 
violence. 

In three of the cases collected by Malsraigne, union failed in both 
bones, and he has left a very complete account of the resultant disability 
in one of them which was under his own care. In the others there was 
apparently but little permanent interference with the functions of the 
arms. In recent cases there is sometimes considerable dyspnoea, which 
Hurel thinks is due to the weight of the arms and shoulders upon the 
thorax, aided perhaps by the loss of power of the accessory muscles of 
respiration, those which pass from the neck or thorax to the clavicle and 
scapula. This dyspnoea is relieved by the dorsal decubitus if the shoul- 
ders rest upon a firm support. The condition of Malgaigne's patient on 
examination three years after the accident was as follows ; the shoulders 
appeared to be below, in front, and on the inner side of their normal 
positions, the shoulder-blades stood out posteriorly three or four inches 
from the chest-wall and were inclined forwards and outwards, and the 
upper part of the chest seemed much contracted. The clavicles were 
broken at the centre, and the outer fragments were below T and behind 
the inner ones. The shoulders could be drawn back slightly, but not 
enough to overcome the displacement forward, and they could be 
drawn forward so far that they were separated by an interval of only 
three inches, measuring across the chest. The arms could be raised to 
the horizontal line in front and on the side, but not behind. 

Symptoms and Course. — The rational and physical signs common to 
most fractures are found in those of the clavicle. These are the de- 
formity, mobility, and crepitation, the localized pain, and the diminution 
of function. Besides the deformity due to the displacement of the frag- 
ments, there is also that which is produced by the falling inwards of the 
shoulder and which is most apparent when viewed from behind, and with 
it goes a very noticeable projection of the posterior border and inferior 
angle of the scapula. These signs are of course most marked in cases 
of complete fracture with overriding of the fragments; in fractures of 



FRACTURES OF THE CLAVICLE. 335 

the inner and outer thirds they are usually less marked, or even absent, 
because the average displacement is less. 

In fractures of the middle third there is usually displacement of such 
a character and extent that there is no difficulty in recognizing it and its 
cause ; the fragments can be separately grasped and moved upon each 
other. Crepitation, however, is not always produced by this manoeuvre, 
for the broken surfaces may not be in contact, and in order to get this 
symptom it is necessary to have the shoulder drawn backward and out- 
ward, so as to reduce the displacement. 

The fixed pain is a valuable sign in partial fractures and in fractures 
without displacement, and it may be the only one that is present imme- 
diately after the injury ; the appearance within a week of a firm oval 
mass at the point where pain was felt confirms the diagnosis of fracture. 
The only probable source of error in such a case would be a periostitis 
due to direct violence which might give rise to a similar lump. 

The interference with function seems to be largely the consequence 
of the pain which makes the patient unwilling to move the arm, rather 
than of any mechanical defect produced by the fracture. It was long 
taught that a patient with a broken clavicle could not raise his hand 
to his head, but this is so far from being the fact that Velpeau declared 
he had not met w T ith two cases in twenty years, in which there was this 
disability. The patient can usually move the arm quite freely back- 
wards and forwards, but cannot raise it or adduct it without pain, and if 
asked to put his hand on his head, will usually flex the forearm, incline 
the body, and bend down his head to accomplish it. The fracture and 
displacement are not entirely without influence in this limitation of the 
movements, but they are not wholly responsible for it. Hurel, 1 who 
profited by his internat at the hospital for convalescents at Paris, to ex- 
amine the later condition of patients with this fracture, found the move- 
ment of circumduction of the arm the last to be regained, and that a 
shortening of half an inch or more dela} r ed complete recovery consider- 
ably beyond the time that was sufficient for it when the shortening was 
less or absent. 

The patient's appearance is often quite characteristic ; he sits with his 
body and head inclined towards the injured side and supports the elbow 
or forearm with the other hand, and some surgeons have held that the 
diagnosis could be made by the simple inspection of the posture. The 
only cases in which the diagnosis can well remain in doubt after even a 
brief examination are those of incomplete fracture, and some of fracture 
close to either end of the bone. The latter may be mistaken for dislo- 
cation ; in fact, one was so mistaken — a fracture of the sternal end under 
the care of Be'clard, at La Pitie, the real character of the lesion appear- 
ing at the post mortem. This error may be avoided if the outline of 
the bone can be accurately traced, but in two cases of dislocation of the 
acromial end of the clavicle with slight occasional crepitation, I have 
found it impossible to determine positively the seat of the accompanying 
fracture, which was, probably, a partial one, running into the joint. 

The progress of the fracture is extremely simple and is rarely dis- 

1 Les Fractures de la Clavicule, These de Paris, 1867. 



336 FRACTURES OF THE CLAVICLE. 

turbed by complications or dangers. Union is usually firm by the end 
of the fourth week, sometimes much earlier, and failure of union is rare. 
Displacement and shortening, however, are the rule, only those cases, 
apparently, being exempt in which the line of fracture is transverse and 
there is no displacement at first. The amount of the shortening may 
vary from a fraction of an inch to one and even two inches, and it may 
be produced by angular displacement, or by overriding, or by both, as in 
figure 169. 




Fracture of the clavicle. Union with extreme displacement. 

The complications that may occur in the course of the repair are the 
ordinary inflammatory ones that may arise at the seat of fracture in con- 
sequence of the bruising of the surrounding parts, or of the failure to 
immobilize the fragments, or special ones due to the pressure of the frag- 
ments or callus upon the vessels and nerves. Cases have been already 
given in illustration of these complications when produced at the time 
of the accident ; those of later occurrence are very exceptional, although 
Delens 1 intimates a belief that the diminution of power observed in some 
cases after recovery may be due to compression of the nerves by an ex- 
uberant callus. Besides his own case Delens was able to find only one 
other, Polaillon's. 2 A few cases in Gurlt's chapter upon fractures of the 
clavicle may perhaps be instances of paralysis due to the pressure of 
a large callus, but it is not possible to distinguish positively between 
the primary and the secondary effects. Delens's case is very satisfac- 
tory. The patient was brought to the hospital, January 1st, 188 L, with 
fracture of the left clavicle and two ribs. The arm was placed in a 
Mayor's sling, and union was complete by the end of the month. The 
patient returned on the nineteenth of March, complaining of great loss of 
power in the left arm ; examination showed marked overriding of the 
fragments, the outer lying in front of the inner one, with a hard firm 
callus two inches thick, atrophy of all the muscles of the left arm, and 
passive congestion of the skin of the hand ; the pulsations of the left 
radial artery were much weaker than those of the right. The posterior 
and lower portion of the callus was removed by operation, the pulsations 
of the radial artery and the appearance of the hand at once became 
normal, and the patient gradually recovered the use of the limb. 

In another case Grosselin removed a portion of callus which had 
caused persistent ulceration of the soft parts covering it. A prompt 
cure followed. 

1 De la resection d'un cal de la Clavicule comprimant les vaisseaux et les nerfs 
sous-claviers, in Archives de Medecine, Aug. 1881, p. 170. 

2 Loc. cit., p. 696. 



FRACTURES OF THE CLAVICLE. 337 

Ossification of the coraco-clavicular ligament has been observed in 
several cases after fracture in the outer third. No description is given 
of the modifications, if any, of the functions of the part produced by .this 
ankylosis. 

Failure of union is rare. The fact that in three of the six cases 
of fracture of both clavicles collected by Malgaigne, the bones did not 
unite, led that author to believe that this double fracture predisposed 
strongly to failure of union ; but as no similar failure has been since 
recorded, and as the failure in at least two of these cases appears to 
have been the result of the lack of treatment, the opinion lacks support. 
A few cases of failure of union after fracture have been recorded, and 
it is worthy of note that it does not appear to have resulted in any 
diminution of function ; in one case carefully examined by Hamilton 
where there was ligamentous union and overriding to the extent of half 
an inch the arm on the affected side w r as in every way as strong and as 
fit for use as the other. In the recorded cases of pseudarthrosis the 
fracture has generally been in the middle third, rarely in the inner one. 
In only twa cases has the pseudarthrosis received operative treatment. 
The seton was used in both, and successfully. 

Treatment. — The indications for treatment are to reduce the displace- 
ment and to prevent its recurrence. The means by which they are to 
be met do not differ materially in the different fractures, but in describ- 
ing them I shall have mainly in mind fractures of the middle third. 

As has been already said, the shoulder and outer fragment are usually 
displaced inward, forward, and downward, and the outer end of the 
inner fragment is displaced upward. The force which produces the first 
displacement is the weight of the shoulder. It must be remembered 
that the shoulder han^s out from the chest as a sign hangs out from the 
side of a house ; the scapula and 

clavicle are two lateral supports, Fi g- !7°- 

and the trapezius muscle is a sus- A s 

pensory one. A glance at figure a'-.. ^^v/ 
170 shows how the fracture of the T*^*^^^^ 

clavicle removes one lateral support, \ ^J ^ ^ S^, 

and how the weight of the shoulder, c -11]^^ ^HftjJ* 

being no longer supported upon that 11/ ^\^ 

side, swings forward and inward if \ 

upon the posterior border of the cf /^^^^ 

scapula as a centre, or rather upon ]\ ^L^iP^^ 

the under surface of that bone as ^^r 

it lies in Contact With the rOUnd Mechanism of displacement after fracture of 

, ,-. ., ..., . the clavicle. A, acromion; C, clavicle; S, sea- 

chest wall, until a new equilibrium pula . A , ? position of the acromioil after the frac 
is found. This movement of rota- ture. 
tion carries the posterior portion of 

the scapula away from the back at the same time that it brings the 
anterior portion nearer the front, and as the upper part of the chest is 
dome-like and not simply cylindrical, and as the movement, the change 
of position, takes place therefore in a vertical as well as in a horizontal 
plane, the shoulder drops and the inferior angle of the scapula rises, by 
comparison at least, if not actually. Reduction, therefore, is to be 
22 



338 FRACTURES OF THE CLAVICLE. 

accomplished by carrying the shoulder back to its former position, and 
retention by supplying the support previously given by the clavicle. 
These indications have been clearly understood since the time of the 
earliest writers, but it has been found very difficult to embody them in 
practice, because there is no means of acting in the desired manner upon 
the shoulder that does not involve an amount of discomfort that patients 
will not ordinarily submit to. Moreover, in some cases surgeons have 
lost sight of the fact that the position of the arm is a secondary one, its 
importance being due solely to its use as a means of acting upon the 
outer end of the scapula, and that it is useless to press the elbow upward 
unless the scapula is left free to be raised by that pressure. It is 
entirely useless to bind the elbow to the shoulder on the same side ; such 
dressings do not raise the scapula. 

One of the methods of reduction employed by Hippocrates resembles 
in principle very closely the dressing suggested by Yelpeau and em- 
ployed with much success by him and others. He placed the hand of 
the affected side upon the opposite shoulder and then pressed the elbow 
forcibly upward and outward. As the arm lies thus across the chest 
its long axis is exactly in the direction in which pressure should be 
made to overcome the usual displacement. Another method employed 
by Hippocrates was to place the patient upon his back with a small hard 
cushion between his shoulders, and then to press backward upon the 
acromion or the head of the humerus while the elbow was pushed up by 
an assistant. Paulus iEgineta made extension by drawing the arm 
upward and outward, and counter-extension by the neck or other arm, 
and he also recommended the axillary pad with the elbow brought close 
the side. Guy de Chauliac placed his knee between the patient's shoul- 
ders and drew them backward. These methods are the types of all 
that have since been used or that are now in use. A modification intro- 
duced by Chassaignac deserves mention. Having observed that the 
displacement could be reduced by extreme elevation of the shoulder, he 
proposed the following method : the surgeon places his breast against 
the shoulder of the uninjured side, clasps his hands under the opposite 
elbow and draws it forcibly upward. The principal objection to the 
method is that if the fracture is oblique the reduction cannot be main- 
tained. 

Reduction, in short, is to be sought by carrying the shoulder upward, 
outward, and backward, acting either directly upon it or indirectly 
through the elbow, or using the arm as a lever. Polaillon recommends 
strongly a method based upon the latter principle ; standing behind the 
patient he passes his hand or forearm into the axilla and draws upw T ard 
and backward with it, while with the other hand he presses the 
elbow against the side and thus forces the shoulder outward. 

In some cases it is necessary to have these efforts made by an assist- 
ant in order that the surgeon himself may be at liberty to make such 
movements of coaptation as may be needed to overcome the obstacles 
offered by points or irregularities upon the surface when the line of 
fracture is transverse or nearly so. In transverse fractures with only 
angular displacement upward and forward it is sometimes sufficient to 
make pressure upon the angle. 



FRACTURES OF THE CLAVICLE. 339 

The physical obstacles that need to be overcome in the treatment are 
so great, and the success that has attended the different methods has 
been so moderate that the number of plans that have been proposed and 
employed is very great, and the history of the treatment shows mainly 
a recurrence of periods marked at first by elaboration and multiplication 
of details and precautions and then by the abandonment of them all and 
the substitution of something very simple. The results obtained by 
the simple scarf or sling are as good as those furnished by the most 
elaborate bandaging, and the discomfort to the patient during treatment 
is much less. 

The differences in the methods depend in great part upon the indica- 
tion which each surgeon has had more particularly in mind, upon the 
displacement which he sought to prevent. Thus, in some the special 
object of the dressing is to maintain the shoulder elevated, in others to 
hold it back, and in others again to draw it outward. The type of the 
first class is a band passing under the elbow and forearm and around 
the neck, the forearm lying across the chest. That of the second is a 
posterior transverse splint to the ends of which the shoulders are made 
fast, or an anterior transverse splint pressing the shoulder back. That 
of the third is the axillary pad used as a fulcrum to force the shoulder 
out by pressing the elbow in. 

When the patient is sufficiently desirous to avoid any visible irregu- 
larity in the outline of the clavicle to bear the discomforts of a prolonged 
rest in bed without change of position, and w T hen the displacement can 
be reduced, treatment in the recumbent position holds out the best pros- 
pect of recovery without deformity. The patient should be placed upon 
his back (or rather upon her back, for it is not probable that any one 
but a lady whose social position requires her neck to be left at times 
uncovered will submit to this confinement), upon a firm mattress with 
the head bent forward so as to relax the sterno-cleido-mastoid upon the 
injured side, and the elbow fastened to the side or chest or raised upon 
a cushion so that the weight of the arm may tend somewhat to force the 
shoulder upward and backward, anatomically speaking. It has been 
recommended also that a firm narrow cushion be placed along the spine 
between the shoulder blades, and Robert preferred to have the patient 
lie not entirely flat upon the back, but inclined slightly toward the un- 
injured side. In one case digital pressure was made upon the frag- 
ments throughout the treatment to insure accurate coaptation. Mal- 
gaigne suggested that blunt hooks with a strap fastening them to the 
elbow, or double hooks like those he used in fracture of the patella, 
might perhaps be substituted for the fingers of the assistant. The 
position must be kept practically unchanged for at least two, and proba- 
bly for three, weeks. 

Quite recently L.angenbuck 1 has used the silver suture. The patient 
was a boy ten years old, the fracture at the junction of the outer and 
middle thirds. The fragments were fastened together with silver 
sutures, both ends cut short, and the periosteum united with catgut 

1 Deutsche Med. Wochensclirift, Jan. 28, 1882. 



340 



FRACTURES OF THE CLAVICLE 




<5 

Fracture of the clavicle 
scarf. 



Mayor's 



sutures. Antiseptic dressings and the Desault 
bandage were used. The result is said to 
have been very good. The scar left by the 
operation would probably be considered as 
objectionable a disfigurement as union with 
the average displacement. 

Mayor's Scarf or Sling (fig. 171) is 
made of a square of muslin the diagonal of 
which is long enough to extend easily 
around the body. The forearm is flexed at 
a right angle and laid across the breast ; the 
cloth, folded diagonally, is laid over it and 
tied around the body so that its folded bor- 
der runs horizontally around an inch or two 
above the forearm, in front of which the 
cloth hangs down. The free point of the 
triangle is then brought up between the 
forearm and the body, and the two folds of 
which it is composed are secured, one on 
either side of the neck, by bands attached 
to the scarf behind and brought forward over the shoulder. 

A modification which makes this more secure was used by Grosselin, 
The forearm rests* between the folds of the triangle, the folded diagonal 
of which thus forms the lowest part of the dressing, while its ends are 
tied around the body as before. The folds that form the third point are 
also secured as before, or, if long enough, are tied together about the 
neck. Richet sought to give additional solidity by adding bands of ad- 
hesive plaster, passing them under the elbow 
and across the opposite shoulder. 

This method is suitable for fractures without 
much displacement, especially for those in 
children with untorn periosteum. 

Velpeau's dressing (Fig. 172) is more 
secure. It is made with a long roller band- 
age. The elbow is brought well in front of 
the chest and the hand placed on the opposite 
shoulder, and the limb is drawn snugly up 
towards the neck by successive turns of the 
roller which, beginning at the opposite axilla, 
pass obliquely across the back, over the shoul- 
der, in front of the arm, under the elbow, and 
back to the axilla ; after three or four such 
turns have been placed the bandage is carried 
circularly around the body covering in the arm 
from below upward. The turns should be 
secured by stitching or by soaking in dextrine or plaster. 

Say re's dressing (figs. 173 and 174). A very convenient and 
popular dressing is the one introduced by Prof. Sayre. It is made of 
two strips of adhesive plaster, each about three inches wide and long 
enough to go once and a half around the body; one end of the first strap 




Velpeau's dressing for fracture 
of the clavicle. 



FRACTURES OF THE CLAVICLE. 



341 



is stitched loosely about the arm just below the axilla, and the other 
carried around the chest from behind forward, as shown in figure 173. 
The second strap is then carried from the top of the shoulder on the un- 
injured side across the back, under the elbow, and along the forearm to 
the shoulder again (fig. 171). The elbow should be drawn back while 



Fiff. 173. 



Fig. 174. 





Sayre's adhesive plaster dressing for fracture 
of the clavicle. First piece. 



The same. Second piece. 



the first strap is applied, and well forward while the second is. It is a 
convenience to the patient to have the plaster carried past the ulnar side 
of the hand so as to leave the latter uncovered. The action of the 
dressing is simply to press the shoulder upward and backward, and its 
principal advantage lies in the solidity which the use of the adhesive 
plaster gives ; sometimes a turn of a roller bandage is placed under the 
plaster to prevent irritation or excoriation. 

The axillary pad, designed especially to prevent shortening by forc- 
ing the shoulder outwards, has been in use for many centuries, and 
reached its highest development at the hands of Desault, of whose com- 
plicated dressing it forms the essential part. He made it of a firm, 
wedge-shaped cushion stuffed with hair, long enough to reach from the 
axilla nearly to the elbow, four or five inches wide, and three inches 
thick. It was placed between the arm and the body with its thick 
base in the axilla, and the elbow was then brought down and fastened 
to the side with a roller bandage. Numerous other turns of the band- 
age were carried under the elbow and over the shoulders to force the arm 
upward and backward. Desault' s dressing was cumbersome and liable 
to slip, and the axillary pad has on more than one occasion caused gan- 
grene of the arm by obstruction of the circulation, or paralysis by pres- 
sure upon the nerves. As now used it is smaller and softer, but, I 



342 



FRACTURES OF THE CLAVICLE. 



believe that whenever it is large and firm enough to accomplish its 
object, it is dangerous, and whenever small enough to be free from 
danger it is useless. It still forms part of many dressings, but I do not 
think its use in its more recent form can be justified theoretically, or 
that the results obtained by it are better than others. I shall, there- 
fore, mention only one dressing of which it forms part, a dressing that 
has been highly spoken of in the past and which is still very popular, I 
believe, in Philadelphia. It was introduced into the Pennsylvania Hos- 
pital by Dr. George Fox, in 1828. 

Fox's dressing (figures 175, 176) consists of an axillary pad, a 
stuffed leather ring, and a sling. The ring is passed over the arm of the 



Fig. 175. 



Fig. 176. 




Fox's dressing for fracture of the clavicle. 



Fox's dressing for fracture of the clavicle. 



uninjured side to the shoulder, and the pad and sling are attached to it 
by straps, as shown in the accompanying figures. Dr. Agnew speaks 
highly of its value in the treatment of fractures of the sternal or acromial 
end of the bone. 

Papini's Brace. — An attempt to meet the same indication by means 
of a fixed brace has been made by Papini, and the instrument seems to 
be well adapted to its purpose. It consists of an artificial clavicle of 
wood made fast to the body and shoulder by a jacket and armlet of 
leather. The arm is secured to the side and the elbow held up by a 
roller bandage. It is adjustable, so that the shoulder can be pressed 
back to the desired extent. 

The dressings which are intended mainly to draw the shoulder back- 
ward are modifications of the figure-of-8 bandage and the posterior and 
anterior splints. The simple figure-of-8 carried across the back from one 
shoulder to the other, is, if not actually harmful, certainly inefficient. 
A modification suggested by Recamier amounts almost to a posterior 
splint. He placed a large, hard square cushion (fig. 177) between the 
shoulders behind and carried a bandage from each upper corner over the 
shoulder and under the axilla back to the lower corner. Moore, of 
Rochester, applied the bandage so as to include the elbow as well as the 



FRACTURES OF THE CLAVICLE. 



843 



shoulder of the affected side, seeking to make the fibres of the pectoralis 
major tense by drawing the elbow backward. The bandage in his dress- 
ing (fig. 178) should be about two yards long, its centre is placed under 
the olecranon, the forearm be- 
ing flexed at a right angle, the 
end that is next the body is 
carried up between the arm 
and the side, in front of and 
over the shoulder, across the 
back and under the opposite 
axilla ; the other end is carried 
around the outer side and 
front of the elbow, then be- 
tween it and the side to the 
back, and across the back to 
the opposite shoulder where it 
is made fast to the first end. 
The elbow must be drawn 
backward and pressed upward.' 
Hamilton expresses approval 
of the principle of this dress- 
ing, but finds its use trouble- 
some to the patient. I do not 
think it is worth while in any 
dressing to seek to draw down 
the inner fragment through the 
agency of the pectoralis major. 

Posterior splints are seldom used now. They have been made in the 
form of a cross, against the arms of which the shoulders were drawn 
back, and as iron, wooden, and pasteboard splints crossing the back and 
extending usually beyond the shoulders, so that the traction of the 
bandages by which the shoulders were made fast should be exerted in 
an outward direction as well as backward. . 

Anterior splints, made of gutta percha or metal, and moulded to the 
front of the chest from one shoulder to the other, have been used with 
the same object, and the attempt has been made to use plaster of Paris 
in the same manner, pouring it over the front of the shoulder and chest 
to solidify while the fragments are held in position. 

I am not aware that the plaster-of-Paris jacket has been used for this 
purpose, and I have had no suitable opportunity to make trial of it ex- 
cept in the somewhat similar dislocation of the acromial end of the clavi- 
cle, but I think it would furnish a fixed point that could be made useful 
by fastening the shoulder to it by additional turns of the bandage. 

It is very apparent upon examination of the history of this subject, 
that w T hile many different dressings may give good results in certain 
cases, none can be depended upon to do so in all, and that the dis- 
placement, the shortening, which is the rule, is the result in some cases 
of forces which cannot be effectually controlled, of the obliquity of the 
fracture, and not infrequently of the indocility of the patient, who, find- 
ing himself incommoded by the dressing, shifts it slightly, but often, 




Fracture of the clavicle. Kecamier's dressing. 



344 



FRACTURES OF THE CLAVICLE. 
Fig. 178. Fig. 179. 




Moore's dressing for fractured clavicle. 



Moore's dressing for fractured clavicle. 



until he obtains ease at the sacrifice of the object it was applied to 
secure. 

If the fracture is without displacement, especially the subperiosteal 
fracture of children, or if the displacement shows but little tendency to 
recur after reduction, the simple scarf or sling or Sayre's dressing will 
answer every purpose. 

If, on the other hand, the tendency to displacement is great, the 
choice of a method of treatment will depend largely upon the character 
and wishes of the patient. If he is indifferent to the deformity or intol- 
erant of restraint, it is useless to attempt more than a simple dressing ; 
but if he is willing to submit to the confinement, the fracture may be 
treated by dorsal decubitus and digital pressure with a fair prospect of 
success. 

If the displacement is irreducible, as sometimes happens, and without 
much tendency to increase, a simple dressing is sufficient. 

In simultaneous fracture of the two clavicles, the dorsal position is 
strongly to be recommended. 

It is well to place in the axilla a pad of cotton wrapped in a compress 
to absorb the moisture and keep the opposing surfaces from contact with 
each other ; and for the same reason a compress should be placed be- 
tween the arm and the body, wherever the two would otherwise be in 
contact. 

If an axillary pad is used, particular attention must be paid to the 
condition of the circulation and innervation, and the examination must be 
made twice or three times a day at first. 

The dressing should be worn for from fifteen to twenty days by chil- 
dren, and twenty to thirty days by adults. 



FRACTURES OF THE SCAPULA. 



345 



CHAPTER XX, 



FRACTURES OF THE SCAPULA. 

Fractures of the scapula are comparatively rare, about one percent, 
of all fractures according to the best statistics at our command. They 
are six times as common in men as in women, and in the great majority 
of cases the patients have been between twenty and fifty years of age. 

The size and shape of the bone, and the presence of three irregular 
and prominent apophyses permit a diversity of fractures differing so 
greatly in their mode of production and symptoms that it becomes neces- 
sary to consider them separately. Most writers in the last hundred years 
have made from six to eight groups as follows : 1st, fractures of the body ; 




Transverse fracture of the sternum. Fracture of the clavicle ; union. 

2d, fractures of the inferior angle ; 3d, fractures of the upper angle and 
supra-spinous fossa ; 4th, fractures of the spine ; 5th, fractures of the 
acromion ; 6th, fractures of the coracoid process ; 7th, fractures through 
the surgical neck ; 8th, fractures of the glenoid cavity. Of these 



346 



FRACTURES OF THE SCAPULA 



Fig. 181. 



varieties the 1st, 4th, 5th, and 7th are by far the most common, the 
others are extremely rare. 

1. Fracture of the Body of the Scapula. — Fractures of the body of 
the scapula are single or multiple. The former are confined to the sub- 
spinous fossa, and the direction of the line of fracture is transverse or 
oblique. The fragments may preserve their normal relations to each 
other or there may be displacement, the lower fragment shifting to either 
side of the upper one and overriding for a greater or less distance. This 
overriding is most marked on the axillary side and is due apparently to 
muscular contraction, while the lateral displacement is the result of the 
continued action of the fracturing force. In some cases the fragments 
have united after transverse or oblique fracture in such a position that 
they touch or override at one side and are separated at the other. 

In multiple fractures the lesion is extremely variable, the fracture may 
be " starred," or comminuted, some of the lines may be incomplete, and 

the main one may be longitudinal ; 
the only condition, apparently, under 
which longitudinal fracture is met 
with (fig. 181). Gurlt doubts if a 
simple longitudinal fracture was ever 
known, although he quotes a case from 
the Lancet (1862, vol. ii. p. 116) 
described as such. 

Malgaigne describes a case of sup- 
posed partial fracture, the diagnosis 
being made during life. The central 
portion of the bone was found de- 
pressed after a blow, with a sharp, 
well-defined, bony margin on the 
spinal side, and rising gradually to 
the level of the bone on the other ; 
no crepitation or abnormal mobility. 
Dr. Hamilton describes a partial 
fracture or fissure found in the 
scapula of an Oneida Indian who 
died of injuries received a few months 
previously in a street fight. The fis- 
sure ran from a point on the posterior border three-fourths of an inch 
below the spine transversely across the body of the scapula for 1} inches. 
There w T as no displacement and no union, but there was a ridge of callus 
along each side of the fissure. Gurlt gives a figure of a specimen 
showing what seems to be a marked infraction of the body below and 
parallel to the posterior half of the spine. 

The cause of the fracture has always been direct violence, usually a 
blow or a fall upon some angular object, but in two cases it was caused, 
with other injuries, by the passage of a locomotive, the patient having 
fallen between the rails and been squeezed between the ground and the 
ash-box as it passed over him. 

The objective symptoms which may be met with are irregularity in 
outline, abnormal mobility, crepitation, and ecchymosis. The posterior 




Multiple (longitudinal) fracture of th< 
scapula. 



FRACTURES OF THE SCAPULA. 347 

border of the bone can be brought into prominence by carrying the fore- 
arm across the chest or behind the back, and then if the finger is passed 
along it a transverse or oblique fracture with displacement will be certainly 
recognized. Abnormal mobility and crepitation are not so readily made 
out, the best plan is to pass the fingers if possible under the inferior 
angle and thus ascertain if it moves independently of the rest of the 
bone. To detect crepitation the palm of one hand should be placed over 
the bone and the arm moved freely in different directions. In multiple 
or partial fractures with depression the adjoining edge of bone may be 
felt, as in Malgaigne's case, if the patient is not too fat or muscular. 
The precaution should always be taken to make a comparison with the 
other scapula, and the normal ridges along the borders and at the base 
of the spine should be borne in mind. Ecchymosis unless due to the 
action of- the violence upon the soft parts, seldom appears until after the 
lapse of a few days. Emphysema was spoken of as a symptom by Petit, 
but has been noticed by no subsequent observers; possibly it was due in 
his cases to concomitant fracture of the ribs and wound of the luns;. 

Localized pain on pressure and on movement of the arm is a constant 
symptom, and may make it impossible for the patient to extend his arm 
horizontally and directly forward because it is so much increased by the 
contraction of the muscles concerned in this movement. 

The course in the simpler cases ends in recovery in four or five weeks, 
usually with preservation of function even if union has taken place with 
some unreduced displacement. Multiple fractures are more dangerous 
because of the greater probability of suppuration at or in the neighbor- 
hood of the fracture, and of course if the fracture is a compound one the 
danger is still greater. In a very few instances there has been much 
disability due to failure of union or to union with displacement and ex- 
uberant callus. Gurlt quotes an example of the former in which the 
patient was unable to raise his hand to the back of his neck, and one of 
the latter in which the disability was almost complete and all communi- 
cated movements of the arm and shoulder painful. 

Treatment. — In simple fracture without displacement no other treat- 
ment is needed than immobilization of the arm and shoulder during the 
length of time necessary for consolidation. If displacement exists it 
must be corrected if possible, but no rules have been laid down by which 
this may be accomplished, no special principles even established by at- 
tention to which the attempt is made more likely to succeed. Great 
diversity exists in the recommendations made by different writers, and 
unfortunately each has to admit the possible failure of his method. Mal- 
gaigne, indeed, after an elaborate description of the mechanism of displace- 
ment and of the means by which it should be reduced and prevented, admits 
that he had never been able even to reduce it, and that sometimes the 
manoeuvres and" positions which seemed best calculated to diminish it only 
increased it. The surgeon therefore should seek to recognize the charac- 
ter of the displacement as clearly as possible, and then should try to 
reduce it by placing the arm and shoulder in various positions and 
pressing upon the fragments with his hands in the directions indicated 
by the displacement. When the latter is reduced as far as possible the 
arm and shoulder must be immobilized by bandages that raise the elbow 



348 FRACTURES OF THE SCAPULA. 

and fix it to the side, and broad strips of adhesive plaster should be laid 
across the scapula to aid in its immobilization. Moulded splints of 
pasteboard, gutta percha, and plaster of Paris have been suggested and 
employed, but they do not furnish enough additional security to com- 
pensate for the discomforts they may cause. 

In comminuted fractures the principal indication is to prevent the 
severe inflammatory reaction which is so likely to follow the bruising 
and laceration produced at the same time by the extreme violence that 
has caused the fracture. If the fracture is compound it must be ex- 
plored through the wound and treated in accordance with the principles 
elsewhere laid down, and I believe that it is prudent in such cases to 
remove partly adherent fragments which could be safely left after frac- 
ture of other bones, whenever by such removal a free outlet that would 
otherwise be lacking is supplied to matter that may accumulate on the 
under (costal) surface of the bone. The experience furnished by frac- 
tures of other flat bones, the skull and sternum, shows the probability of 
suppuration on the under side, and in a few cases of fracture of the 
scapula pus has formed in this manner and caused much trouble by 
burrowing down the side. In one case of simple fracture the surgeon 
felt justified in cutting down upon the bone and removing a large num- 
ber of fragments, but the practice has not been approved by any one 
who has quoted the case, at least not to the extent of laying it down as 
a rule for general application. 

Fractures of the Inferior Angle. — These are included by some sur- 
geons, and with good reason, in the group of fractures of the body of 
the scapula, from which they differ merely by the proximity of the line 
of fracture to the lowest part of the bone, but as they present a more 
constant and well-defined displacement which cannot be readily overcome 
or prevented they deserve separate mention. The recorded instances of 
separate fracture are not very numerous. Gensoul reported one pro- 
duced by muscular action ; the patient saved himself from falling to the 
ground while descending a sharp incline, either by catching hold of some 
support or by falling backward upon his outstretched hand, the abstracts 
of the report are not very clear upon this point. A triangular piece 
corresponding to the inferior angle was detached from the scapula and 
displaced forward and upward, and could be moved independently and 
with crepitation. Grensoul attributed the fracture to the sharp contrac- 
tion of the teres major. In other cases the cause has been a fall upon 
the back. 

The symptoms, apparently, are clear and unmistakable ; displacement 
of the fragment forward and upward by the combined action of the serra- 
tus magnus, teres major, and, according to some, of the latissimus dorsi; 
abnormal mobility recognized by grasping the fragment with one hand 
and moving it, or by fixing it with one hand and moving the scapula 
with the other ; and crepitation. 

The displacement is difficult to reduce or maintain reduced, because 
the smallness of the fragment prevents efficient control of it, and the 
tonicity of the muscles tends constantly to draw it away ; but while this 
insures some deformity it is slight and does not add seriousness to the 
prognosis. It has been proposed to overcome the displacement by 



FRACTURES OF THE SCAPULA. 



349 



carrying the upper fragment forward to a position corresponding to that 

of the smaller one, moving the arm forward and upward so as to make 

the connecting muscles tense, 

but those who propose this seem 

to have overlooked the fact that 

the lower fragment would be 

acted upon at the same time, and 

in the same manner and to the 

same degree so that the parts 

would preserve their relative 

positions and the displacement 

would remain. 

Fractures oftlie Upper Angle. 
— These are very rare. Gurlt 
gives a figure of a specimen 
preserved in Dresden, and Ham- 
ilton, of one in Philadelphia. 
In the latter (fig. 182) a fissure 
extends well into the subspinous 
fossa. In both repair has taken 
place without much displacement. 
Gurlt records two cases observed 
during life ; in each the injury 
was the result of a fall upon the 
back ; in one there was no dis- 
placement, in the other the frag- 
ment was drawn upward and 
inward by the levator anguli 
scapulae. 

The treatment is to immobilize the arm and shoulder in the position 
that is most comfortable, securing the scapula with a body bandage or 
strips of adhesive plaster, and the arm by binding it to the body with 
the forearm flexed across the chest. 

Fractures of the Spine of the .Scapula. — There are no known speci- 
mens of isolated fracture of the spine of the scapula, and our only 
knowledge of them is clinical and based upon a few cases. Of these the 
following seem demonstrative. 

A delicate lad, 18 years old, was struck on the side of the head, and 
fell, striking upon his right shoulder. There was no pain or disability 
at first, but the next day there was pain in the shoulder which interfered 
with the movements of the arm. There was mobility of the spine, crepi- 
tation, pain at the seat of fracture, no displacement, no swelling. It 
was dressed with a simple bandage, and was well in a month. 

A man 38 years old fell upon the right shoulder ; the pain was severe, 
but the limb was freely movable. Examination the next day showed 
distinct crepitation along the entire length of the spine of the scapula. 
The treatment, was Mayor's sling, leeches, etc. 

Dornec 1 reported the case of a child 2 J years old, that had fallen upon 




Fracture of the posterior angle of the scapula. 
(Hamilton. j 



1 Dictionnaire Encyclopedique, art. Omoplate, p. 287. 



350 FRACTURES OF THE SCAPULA. 

his right shoulder. He continued to use the arm, and it was not until 
a fortnight afterwards that the mother noticed a lump upon the shoulder 
and felt crepitation. This lump was very apparent, and could be made 
to appear and disappear by pressure upon it, or by carrying the shoulder 
forward ; it was distant nearly an inch from the posterior end of the 
spine. Movements communicated to the inferior angle did not disclose 
abnormal mobility or cause crepitation. 

The treatment is as before ; immobilization of the arm in a suitable 
position, and local antiphlogistic remedies if required. 

Fracture of the Acromion. — The alleged frequency of this fracture 
has been called in question by those who consider most of the museum 
specimens examples either of a traumatic separation of the epiphysis or 
of non- Ossification. The former would still belong under the head of 
fractures, and, even if we exclude the others, there are still clinical 
instances in sufficient number to make the lesion one of the most com- 
mon. Of 54 cases tabulated by Agnew, 1 in 41 of which the seat of the 
fracture was stated, 12 were of the acromion, 9 of the body, 10 of the 
spine, 5 of the neck, 4 of the inferior angle, and 1 of the glenoid cavity. 
As will be seen, the relative frequency, according to this table, differs 
somewhat from that quoted above. 

The acromion is exposed to fracture by blows received directly upon 
it, and also through the humerus, as in a fall upon the elbow ; and a 
case was mentioned in Chapter IV., in which it was broken by muscular 
action. The line of fracture is usually perpendicular to the axis of the 
apophysis, but is sometimes oblique. It lies most frequently either in 
front of the acromio-clavicular joint, or at the root of the acromion, 
rarely at an intermediate point. Gurlt found it from 2 J to 3 centi- 
metres behind the tip of the acromion in six cases, and at the root in 
only two. In five cases, seen by Hamilton, it was in front of the clavicle 
in two, at the clavicular joint in two, and behind it in one. The peri- 
osteum may remain untorn and the fragment undisplaced. 

The symptoms are those of the fracture and of the contusion, if the 
agency has been direct violence, and as the latter are prominent, and 
may obscure the former, a fracture may be mistaken for a simple con- 
tusion. The signs common to both are ecchymosis, local or extending 
down the arm, swelling, and pain. The additional signs of fracture are 
increase of the local pain on pressure and on moving the arm, usually 
complete inability to abduct the arm, displacement, abnormal mobility, 
and crepitation. 

The displacement varies with the position and extent of the fracture. 
If the latter involves only the outer end of the apophysis, the displace- 
ment is slight and downward by the contraction of the attached fibres of 
the deltoid, the shoulder loses a little of its roundness in consequence, 
but the head of the humerus retains its place. If the fracture is near 
the base of the apophysis, the weight of the arm tends to draw the frag- 
ment downward and inward, turning it upon the outer end of the clavi- 
cle as a centre, and the shoulder is much flattened. The finger passed 
along the spine recognizes an irregularity in the outline, usually a de- 

1 Surgery, vol. i. p. 872. 



FRACTURES OF THE SCAPULA. 351 

pression of the outer fragment, but sometimes an elevation or a trans- 
verse groove or gap in which the end of the finger can rest. 

Crepitation can often be got by lifting the elbow directly upward, so 
as to push up the acromion, or by abducting the arm ; and abnormal 
mobility must be sought by varied manipulations of the apophysis and 
by moving the arm. 

In one of the cases observed by Dr. Hamilton, in which the fracture 
entered the acromio-clavicular joint, the outer end of the clavicle was 
displaced upward, in others this displacement has been absent. 

The commonest functional disturbance is the inability to raise the arm, 
although this is not a constant symptom, while the power of rotation is 
preserved unaltered, even if somewhat painful. 

Bony union appears to be the exception, the fragments uniting by a 
fibrous bond of greater or less length and solidity ; the rupture or the 
preservation of the periosteum must be of almost controlling importance 
in determining the character of the union. Apparently, bony union 
takes place only when the fragments remain in close contact. The 
vitality of the central portion is greater than that of the fragment, for 
the latter must depend for its blood-supply upon the vessels which pene- 
trate it from its own surface, and some of the specimens show evidences 
of a more efficient or active effort at repair on the central side. In one 
case the distal fragment became necrosed and was cast out, apparently 
in consequence of the excessive inflammation of the overlying soft parts. 

The treatment consists in reduction of the displacement by pressing 
the head of the humerus upward against the acromion, and in preventing 
its return by securing the arm in the position that proves most efficient 
and comfortable. Sir Astley Cooper taught that the elbow should be 
held at a little distance from the side by a pad, in order that the outer 
fibres of the deltoid should not be made tense and the fragment drawn 
down by them. The arm must be bound to the body by a dressing 
similar to those used in the treatment of fracture of the clavicle, one that 
will raise the elbow and immobilize the arm thoroughly. It should be 
worn for about four weeks. Additional security is given by the use of 
fixed dressings, plaster, starch, dextrine, and possibly by a gutta-percha 
splint moulded to the shoulder. 

Fracture of the Coracoid Process. — In most instances this fracture has 
been observed in connection with others of the scapula, humerus, or ribs, 
or with dislocation of the humerus, the result of severe external violence 
that was frequently fatal ; but it has occurred alone by the same mech- 
anism and also by muscular action. The following example of the latter 
is quoted by Gurlt, from CO. Weber. A woman, 38 years old, while 
wringing out some wet clothes felt something snap under her collar- 
bone, and found herself unable to continue her occupation. She was 
very thin, and a fracture of the end of the coracoid process could be 
felt distinctly. Another example has been more recently reported by 
Mr. Hulme. 1 A man, 57 years old, was passing through a wire fence 
on a bank ; he slipped, and in falling his left arm caught in one of the 
wires of the inclosure. He instantly felt severe pain in the fingers, with 

i Lancet, 1873, vol. ii. p. 737. 




352 FRACTURES OF THE SCAPULA. 

loss of power in the arm and inability to raise the elbow. On examina- 
tion, three weeks afterwards, the coracoid process was found broken and 
displaced downward. Gurlt collected three cases in which the fracture 
was caused by moderate violence, and he thinks it may be caused by the 
impact of the head of the humerus in a dislocation. 

The line of fracture is usually about an inch behind the beak of the 
process, but sometimes is further back, passing close to the upper edge 

of the glenoid cavity in a line that cor- 
Fig. 183. responds so nearly to the position of the 

epiphyseal cartilage that some observers 
consider some specimens to be examples 
of separation of the epiphysis, or even 
simply of delay in ossification. Nor- 
mally this conjugal cartilage ossifies at 
about the fourteenth year. In one of 
Malgaigne's and in two of Gurlt's cases, 
the end ot the process was also split 
longitudinally into two pieces, one re- 
maining attached to the tendon of the 
Fracture of the coracoid process. biceps, the other to that of the peeto- 

ralis minor. The displacement is seldom 
great, because the fragment is prevented from yielding to the action of 
the attached muscles by the coraco-clavicular ligament ; still, in one of 
the last-mentioned cases the fragments were displaced more than half an 
inch downward. 

The symptoms are abnormal mobility and crepitation, but are not 
easily recognized, especially if the soft parts be much bruised and swol- 
len ; the depth at which the process is placed, and the thickness of the 
overlying muscles, make it difficult to grasp the process between the 
fingers or to appreciate its independent mobility. Gurlt recommends 
that the process should be grasped between the finger and thumb, one 
being placed under the clavicle and the other in the axilla, and that the 
scapula should then be moved with the other hand or by an assistant ; 
crepitation may perhaps be recognized by this means, even if mobility is 
not. Malgaigne advises that the process be pressed downward in seek- 
ing for mobility. In a large proportion of the cases the injury has gone 
unrecognized because the attention of the surgeon has been confined to 
the more prominent associated injuries, especially when there w T as dis- 
location of the humerus. 

The fracture in itself involves no danger to life, and no probable dis- 
ability, although the union is seldom bony. Of six specimens examined 
by Gurlt bony union was found in only one ; in four cases mentioned by 
him of which our knowledge is only clinical, mobility persisted in two. 
This failure of union does not seem to cause any loss of function. In 
Hulme's case mentioned above, the union was firm but the fragment 
somewhat displaced downward. 

The treatment must be directed to immobilizing the arm in a position 
which will relax, as well as may be, the muscles attached to the process. 
Theoretically, the best position is that in which the forearm is flexed and 
the elbow carried across the front of the chest, but this cannot be carried 



FRACTURES OF THE SCAPULA. 353 

out thoroughly without causing more discomfort than the benefit to be 
obtained by it will warrant ; and it is best, therefore, to simply fix the 
arm against the side with the forearm comfortably flexed. Hulme sought 
to keep the fragment in his case in place by putting a flat piece of cork 
below it and fastening it by means of a broad strip of adhesive plaster 
carried over the shoulder to the back. 

Fracture of the Surgical Neck of the Scapula. — This lesion, which 
was known to the earlier writers, and considered extremely dangerous 
by them, has received especial attention from some of the more promi- 
nent writers of the last century, most of whom, however, have grouped 
in one class fractures both of the neck and of the glenoid cavity. Gurlt 
described them separately, and the separation appears to be amply 
justified. 

This author states that he has found in none of the museums of Europe 
a specimen of fracture of the anatomical neck of the scapula, that is, of 
the bone immediately behind the articular glenoid surface ; and Hamil- 
ton says that he knows of no such specimen in America. 

Under fractures of the surgical neck, Gurlt includes not only fractures 
which pass from the supra-scapular notch in a direction parallel to the 
surface of the glenoid cavity to the axillary border of the scapula, but 
also fractures which pass in front of the base of the coracoid process, or 
even through the upper part of the articular surface, and terminate 
below the attachment of the triceps. His second class — fractures of the 
glenoid cavity — have been found only in connection with dislocations, a 
portion of the articular rim being broken oif. 

In the variety now under consideration the fragment always carries 
with it the attachment of the triceps and usually the entire coracoid 
process ; but the ligaments which bind the coracoid process to the clavi- 
cle and acromion remain untorn, as does 

also a ligament extending from the under Fig. 184. 

surface of the spine of the scapula to the ^^^^^^^ 

eds;e of the glenoid cavity, and they limit , ^%^rfll ^s0*f 

the displacement. ° Lm>y ^wB^Bfif' 

The cases in which this fracture has been j .___%\ -^ ^3fl^ 

verified by dissection are five in number : Xa jHR 

the cases of Duverney,Neill, and Spence, a ^'[jm Hit 

specimen in the museum of Guy's Hospital, 

and another in that of the Royal College of ^^! |j|| 

Surgeons at London. Gurlt describes the ll^lk^m 

first three, and Flower 1 mentions the last ™ \|\\ \ 

two. Agnew 2 refers to two or three \\ 

others, but does not say that they were 

verified by dissection. -He also speaks, '~X££~"££?*' 
but without giving the reference, of a case 

of fracture by muscular action, " in the effort of placing a necklace over 
the shoulder." The exact character of Neill's 3 case is uncertain; in 

1 Holmes's System of Surgery, Am. ed., vol. i. p. 851. 

2 Loc. cit., p. 877. 

3 Am. Journal Med. Sci., new ser., vol. 36, 1858, p. 105. 
23 



354 FRACTURES OF THE SCAPULA. 

Spence's 1 (fig. 184) the fracture passed in front of the coracoid process ; 
in the others it appears to have passed through the supra-scapular 
notch. 

The symptoms of the fracture are the flattening of the shoulder, the 
prominence of the acromion, the absence of the head of the humerus 
from the axilla (where it would be found if the injury were a dis- 
location), the easy reduction of the displacement by raising the 
elbow, its immediate return when the support is withdrawn from the 
elbow, and the crepitation which accompanies these movements. In 
two of Grurlt's cases the fragment could be felt in the axilla. The 
power of voluntary motion of the arm is lost, but passive movements 
are free, and, within certain limits, painless. On the other hand, 
manipulations which reduce the displacement or bring out crepitation 
cause much pain. Sometimes the lower edge of the fragment can 
be felt in the posterior and outer part of the axilla as a hard movable 
body which can be pushed upward, with pain and crepitation, but falls 
back as soon as the pressure is removed. In a case reported by Ash- 
hurst, 2 crepitation was obtained by grasping the parts between the fin- 
gers on the shoulder and the thumb deep in the axilla and rotating the 
arm. There was very slight displacement. The patient was a boy five 
years old, and the fracture was caused by the fall of a shutter upon him. 

The most characteristic symptom is the easy reduction and the imme- 
diate return of the displacement, and it is this which distinguishes it 
most sharply from dislocation of the humerus, the prominent symptoms 
of which are so similar. 

According to Gurlt, bony union is the rule, fibrous union the excep- 
tion, but in both cases with more or less displacement of the fragment 
and the humerus upward and downward. His collection contains only 
two cases of fibrous union ; in one the patient had some use of the arm, 
in the other the limb was entirely useless. In the cases where bony 
union was secured, repair was complete in from four to seven weeks ; in 
some there was slight diminution of the usefulness of the limb, but in 
the majority its use was fully regained. 

It is doubtful if the parts can be supported by any dressing so per- 
fectly that union without any displacement can be secured. The indi- 
cations of treatment are to oppose the constant displacement inward and 
downward by raising the arm and carrying its upper end outward. Sir 
Astley Cooper sought to accomplish this by an axillary pad and a short 
sling for the arm ; Gurlt recommends the same with the addition of a 
gutta-percha splint around the shoulder and a gypsum or dextrine spica. 

Fracture of the Grlenoid Cavity. — In all the instances that are on 
record, this fracture has been discovered post mortem after dislocation 
of the humerus. It is thought to be not uncommon, but, as the diag- 
nosis is practically impossible during life, its frequency cannot be de- 
termined. Usually the fracture is of the inner border of the articular 
surface, but sometimes the outer or lower border has been broken off; 
and Flowei 3 says that fractures have been found running across the 

i Edinburgh Med. Journal, June, 1863, p. 1082. 

2 Trans. Coll. Physicians, Phila., 1875, 3d ser., vol. i. p. 69. 

3 Holmes's System of Surgery, Am. ed., vol. i. p. 851. 



FRACTURES OF THE SCAPULA. 855 

glenoid fossa and even splitting it up into several portions. Gurlt, on 
the contrary, says he has found no instance of general splintering, the 
fracture being limited, in all the cases of which he had knowledge, to 
the border. Agnew gives a figure of a stellate fracture, but does not 
state the source from which it was derived. 

The symptoms cannot be described because no case appears to have 
been recognized during life ; and it seems unlikely that a diagnosis 
could be made with any positiveness. The fragment is small and not 
accessible to direct manipulation, so that the only symptoms would be 
those of a dislocation together with crepitation on reduction, and, per- 
haps, a ready recurrence of the dislocation — signs that may be present 
under a variety of circumstances. 

Treatment must be limited to reduction and immobilization, and the 
latter should be more complete and better guarded than after a simple 
dislocation, because of the greater ease with which the head of the 
humerus can escape from the glenoid cavity when the rim of the latter 
is broken. 



356 



FRACTURES OF THE HUMERUS. 



CHAPTER XXI. 



FRACTURES OF THE HUMERUS. 



The tables in Chapter I. show that while fractures of the upper ex- 
tremity (including the clavicle) constitute more than half of all fractures, 
those of the humerus are less than eight per cent, of all, and this bone is 
less frequently broken than either of the other portions of the limb ; the 
percentages of the largest table are, forearm, 18.175; clavicle, 15.091; 
hand, 11.08 ; humerus, 7.863. 

The following table made up by Gurlt from the statistics of the Berlin 
Hospitals shows the relative frequency in the different parts of the bone, 
periods of life, and sexes. It will be observed that it differs radically 
in some respects from the table in Chapter XIX. The most striking 
points in this table are the frequency of fracture during the first twenty 
years of life, and the preponderance of fractures of the lower end of the 
bone, especially during the same period: — 









Upper end. 


Shaft. 


Lower end. 


Total. 


Age. 










i 








M. 


F. 


M. 


F. 


M. 


F. 


M. 


F. 


1 to 10 . 


3 


1 


7 


7 


34 


10 


44 


18 


11 " 20 . 






9 


2 


9 


1 


18 


3 


36 


6 


21 " 30 . 






3 


. . 


12 


1 


5 


1 


20 


2 


31 " 40 . 






3 




4 


1 


8 


. . 


15 


1 


41 " 50 . 






5 


1 


2 


. , 


1 




8 


1 


51 " 60 . 






7 


4 


6 


3 


2 




15 


7 


61 " 70 . 






6 


2 


6 


1 


1 




13 


3 


71 " 80 . 






1 


1 


1 


1 


•• 


1 


2 


3 




37 


11 


47 1 15 


69 


15 


153 


41 








48 


(3 


2 


84 


194 



The different varieties of fracture may be most conveniently studied 
by arranging them in three groups: fractures of the upper end, fractures 
of the shaft, and fractures of the lower end. The first and third groups 
severally contain varieties that differ materially from one another, but 
the classification is essentially a clinical one, and seems best suited to 
meet the needs of the practitioner who is called upon at the bedside to 
solve one of the most obscure and difficult of diagnostic problems, the 
character of a fracture in the vicinity of the shoulder or elbow joint, and 
who must carefully consider the bearing of the evidence, often scanty 
and indefinite, upon the contrasted possibilities. 

For a remarkable case of longitudinal fracture extending the entire 
length of the bone that cannot be placed in any one of these groups the 
reader is referred to page 47. 



FRACTURES OF THE HEAD. 



357 



1. Fractures of the Upper End of the Humerus. 

In this group will be considered fractures of the head, of the ana- 
tomical neck, through the tuberosities, of the tuberosities, and of the 
surgical neck, and separation of the epiphysis. 

By the anatomical neck is meant the narrow constricted groove lying 
just within the capsule at the edge of the articular cartilage ; and by 
the surgical neck is meant the portion of the bone just below the tuber- 
osities, between them and the insertions of the teres major and pectoralis 
major. 

PATHOLOGY AND COURSE. 

a. Fractures of the Head. — Simple fissures or partial fractures of the 
head of the humerus without associated fracture of the tuberosities or 
surgical neck are very rare. To the two instances which Gurlt quotes 
from Gosselin and Gross, may be added, I think, three others, one de- 
scribed by Malgaigne, the other two by Houel. 

In Gosselin's case there were two fissures extending through the 
articular cartilage and for a distance of about one centimetre into the 
spongy bone. The cavity of the joint contained half an ounce of blood. 
Death was caused by delirium tremens 

fourteen hours after the accident, the Fig- 185. 

nature of which is obscure. 

Gross's case 1 is less demonstrative, 
being a specimen obtained several years 
after the injury. The fracture is de- 
scribed as having extended obliquely 
from above downwards through the head 
of the bone and as having become per- 
fectly consolidated. It had been caused 
by a fall from a carriage. 



MaWicme's case 2 was an extensive 
fracture of the scapula, of the surgical 
neck and of the head of the humerus, the 
two latter not communicating with each 
other. The fracture of the head con- 
sisted of two fissures, one extending 
scarcely through the cartilage, the other 
to the depth of an inch into the spongy 
bone (fig. 185). 

Houel's first case is a specimen in the 
Mu? 63 Dupuytren ; about one-third of 
the head of the humerus has been broken 
off and has reunited. 

His second case, also in the same museum, is a specimen of fracture 
through the head separating a thin fragment entirely covered with articu- 
lar cartilage. The patient was an old woman and died seven or eight 




Fracture of the head of the humerus 
(Malgaigne.) 



1 Gross's Surgery, fifth ed\, vol. i. p. 985. 

2 Malgaigne's Atlas, PL 4, fig. 2. Text on p. 



358 



FRACTURES OF THE HUMERUS. 



months after the receipt of the injury. The fragment was turned com- 
pletely over and not united. The specimen was given to the museum 
by Lenoir, who considered 1 it a fracture ot the anatomical neck. 

The cases are much more numerous in which the articular surface is frac- 
tured in connection with fracture of adjoining parts especially the tuber- 
osities and the surgical neck. A beautiful specimen of fissure extending 
from the surgical neck up to and entirely across the head is in the 
Museum of Bellevue Hospital ; it consists of the part above the fracture 
removed by operation. The history gives no details. 

b. Fracture of the Anatomical Neck^ and Fracture through the 
Tuberosities. — Pure fracture through the anatomical neck is a very rare 
accident, and the possibility even of its occurrence has been doubted by 
modern and recent writers, who are apparently not acquainted with the 
few fresh specimens in existence and who doubt the accepted interpreta- 
tion of those in which union has taken place. Some of the specimens 
are described with a scantiness of detail that leaves the exact limits of 
the fracture somewhat uncertain and perhaps justifies the doubts just 
referred to, and in the descriptions of others the term anatomical neck 
is not used in the strict sense in which it is here employed ; but there 
are a few specimens which seem to place the actual occurrence of this 
lesion beyond question. 

Spence 2 presented to the Edinburgh Medico-Chirurgical Society a 
specimen of fracture of the anatomical neck of the humerus, the line of 
fracture lying between the head and the tuberosities entirely within the 
capsule. The injury was caused by a fall upon the shoulder, and the 
patient, who was an old man, died of apoplexy four weeks afterwards. 
Boyei 3 reported a similar case ; the patient was a woman 60 years 
old, and the fracture, which was caused by a fall 
upon the shoulder, occupied the sulcus between 
the head and the tuberosities. She died on the 
seventh day, apparently of tetanus, and the upper 
fragment was found to have been considerably 
reduced in size by absorption of its spongy tissue. 
I know of no illustration representing a specimen 
of pure fracture of the anatomical neck ; figure 
186 is the nearest. 

The examples of united or partly united frac- 
ture are less demonstrative, because it cannot be 
shown that the line of fracture followed the ana- 
tomical neck throughout ; those that seem ,the 
least doubtful are reported by Sir Astley Cooper, 
Cloquet, and Gross. 

In most of the cases described by the authors 
Fracture or the anatomical as fractures of the anatomical neck the fracture 
neck of the humerus, with has extended through one or both tuberosities, 

slight splintering and frac- , ., , ° , , , c , , c , 

ture of both tuberosities, and usually the expanded end of the shaft has 
(Gurit.) been splintered by impaction. In some cases the 



Fis:. 186. 




1 Gazette des Hopitaux, 1858, p. 272. 

2 Edinburgh Med. Journal, vol. v., 1860. p. 1140. 

3 Traits des Maladies Chirurgicales, fourth ed., 1831, vol. iii. p. 199. 



FRACTURES THROUGH THE TUBEROSITIES. 



359 



line of fracture follows the anatomical neck for a greater or less dis- 
tance, and then diverges from it to (usually) the greater tubero- 
sity, separating the bone into two principal pieces, the upper one of 
which is composed of the head and a small part of the adjoining bone, 
with little, if any splintering. In other and more numerous cases the 
upper portion of the bone is comminuted, or one fragment is impacted 
in the ooher. The mechanism in these latter cases is described as 
being (1st) fracture of the anatomical neck, and (2d) splitting off of 
the other portions by the wedge-like action of the separated head. Even 
if this theory could be proved, the clinical importance of the associated 
fracture of the tuberosities would still make it desirable, I think, that it 
should be recognized in the name, and, therefore, I prefer the term 
fracture through the tuberosities, reserving the other, fracture through 
the anatomical neck, for those rare cases in which the line of fracture is 
strictly limited to that portion, It is, perhaps, unnecessary to add that 
the differential diagnosis cannot always be made upon clinical data, and 
that practically we have to make only three groups : fractures of the 
anatomical neck with or without splitting of the tuberosities ; fracture of 
either tuberosity; and fracture below the tuberosities, or of the surgical 
neck. 

In these fractures through the tuberosities the fragments of the latter 
are generally held together more or less closely by the periosteum and 
the articular capsule, and the head itself is wedged in between them. 
If the impaction is close, consolidation may take place without further 
change in these relations, but it is not uncommon to see the articular 
fragment pushed inward and downward by the rising of the shaft, which 
is drawn up by the retraction of the deltoid. Mr. Jonathan Hutchinson 1 



Fig. 187. 



Fig. 188. 





Fracture of the neck and tuberosities 
of the humerus. 



Fracture through the tuberosities of the humerus. 
Displacement downward of the head. 



called particular attention to this late displacement and to the proba- 
bility that if such a case were seen by any one for the first time, two 



1 Med. Times and Gazette, 1866, vol. i. p. 247. 



360 



FRACTURES OF THE HUMERUS. 



or three months after the receipt of the injury, it would be mistaken for 
an unreduced dislocation. His own attention was called to it by observ- 
ing a supposed dislocation at an autopsy ; the history, given by the 
physician who had treated the case, was that of a fracture of the hume- 
rus a year before, while examination showed a fracture through the 
tuberosities and a descent of the head to a new articular facet just below 
the glenoid cavity. He says he has seen this condition often and has 
seen reduction attempted not infrequently. 

Instead of this gradual displacement downward the upper fragment is 
sometimes turned completely over so that its broken surface is directed 
towards the glenoid cavity and its cartilage is in contact with the broken 
surface of the diaphyseal fragment ; or it may be driven bodily into the 
expanded end of the shaft, or it may be itself penetrated by the inner 
side of the shaft. The accompanying figures represent these different 
displacements as they appear after consolidation has taken place. 



Fig. 189. 



Fig:. 190. 





Impacted fracture of the humerus through th« 
tuberosities. (R. W. Smith.) 



Impaction of the head of the humerus into 
the shaft, with splitting off of the tuberosi- 
ties. (R W. Smith.) 



It has been maintained on theoretical grounds that in a pure intra- 
capsular fracture or in one in which all the periosteal and capsular 
attachments of the upper fragment were entirely severed, this fragment 
would necessarily fail to unite, and that acting as a foreign body it 
would lead to suppuration within the joint and to its own ultimate elimi- 



FRACTURES THROUGH THE TUBEROSITIES. 



361 



Fio-. 191. 



nation. Gurlt says there is no authentic instance on record in which this 
result has been effected, the supposed ones being in his opinion simply 
cases of suppurative disease of the bones forming the joint. It was shown 
in Chapter VI. that fragments of bone could preserve or regain their 
vitality after complete separation from the soft parts and even after 
transplantation to another animal, and we have, therefore, reason to 
believe that an intracapsular fragment may reunite if it remains in 
appropriate contact with the surface from which it has been broken. 
And, furthermore, even if union does not take place suppuration is cer- 
tainly not inevitable; in Houel's second case, quoted above in the section 
on fractures of the head of the humerus, a fragment remained loose in 
the joint for seven or eight months without causing suppuration, and in 
others a similar fragment has remained fixed to the shaft by a periphe- 
ral callus or growth of osteophytes that imprisoned it but did not estab- 
lish vital connections with it. In others, again, the fragment has under- 
gone partial absorption. 

Repair is carried on almost entirely by the distal portion of the bone 
and is marked by an exuberant production of callus and osteophyte 
growths on the surface and sometimes by ossification of the adjoining 
portion of the capsule of the joint. 

Figure 190 represents a specimen described by R. W. Smith 1 in which, 
five years after the accident, "the head of 
the humerus was found to have been drawn 
into the cancellated tissue of the shaft between 
the tuberosities so deeply as to be below the 
summit of the greater tubercle ; this process 
had been split off and displaced outwards; it 
formed an obtuse angle with the outer surface 
of the shaft of the bone. . . . Osseous 
union had taken place along the line of each 
fracture." 

Figure 191 represents another specimen 
described by the same author of "impacted 
fracture of the neck of the humerus, accom- 
panied by fracture of both tubercles." It was 
removed from the body of a woman 40 years 
old who had fallen down a flight of stairs 
many years before and had struck the shoul- 
der violently against one of the steps. The 
appearances (at the time of death) were those 
of dislocation into the axilla, the acromion 
being prominent and the region of the deltoid 

flattened ; but the arm was shortened, the glenoid cavity could not be 
felt, and the shaft of the humerus was drawn upward and inward so as to 
be almost in contact with the coracoid process; the motions of the joint 
were extremely limited and the scapular muscles atrophied. "The 
head of the bone was found to have been separated from the shaft by a 
fracture which traversed the anatomical neck of the humerus. It was 




Fracture through the tuberosi- 
ties of the humerus. Reversal of 
the head. (E. W. Smith.) 



1 Fractures in the Vicinity of Joints, 1854, p. 192. 



362 FRACTURES OF THE HUMERUS. 

reversed in the articulation, so that the fractured surface was directed 
upwards towards the glenoid cavity, and the cartilaginous articulating 
surface thrown downwards towards the shaft, and having assumed this 
position it was driven to a considerable distance into the cancellated 
structure between the tubercles. From this violent impaction of the 
head of the bone into the lower fragment a second fracture resulted 
which split oft* the lesser tubercle along with about two-thirds of the 
greater, and a small portion of the shaft of the humerus, corresponding 
to the upper part of the bicipital groove." 

The entire cartilaginous surface of the head of the bone was not buried 
in the cancellated tissue of the shaft ; its inner part was free, its outer 
part impacted to a depth of nearly an inch. The cartilage remained 
perfect, and was not united to the cancellated tissue of the tubercles and 
shaft. The remaining portion of the upper fragment, beyond the limits 
of the cartilage, was intimately and firmly united with the tissue of the 
tubercles ; the reunion of the broken portions of the tubercles themselves 
was complete. A very similar case is reported by Kronlein in the 
Deutsche Zeitschr'ft fur Chirurgie, 1874, p. 1. 

c. Fractures of the Tuberosities. — Isolated fracture of either tuber- 
osity is so rare an accident, except in connection with dislocation of the 
shoulder, that very few cases are on record, and none that have been 
verified by direct examination. Partial fracture of the greater tuber- 
osity, that is, the fracture of a larger or smaller portion comprising some 
or all of the facets to which the supra-spinatus, infra-spinatus, and teres 
minor muscles are attached, is apparently a not infrequent accompani- 
ment of dislocation of the humerus inward, and has also been seen by 
Mal^aigne 1 in a case of dislocation backward under the acromion. Frac- 
ture of the lesser tuberosity is much more rare. 

A number of cases have been reported of fracture of the greater 
tuberosity with symptoms so closely resembling those of dislocation, that 
the diagnosis of the latter lesion was at first made in each case. The 
first case was observed by Mayo, and published by Bransby Cooper, 2 as 
follows : " A gentleman, aged 60, in going up a flight of stairs fell, and 
in the attempt to recover himself fell again. When he was lifted up his 
left arm was useless and the shoulder in pain. On examining it within 
an hour after the accident, my first impression was that it was a dislo- 
cation of the shoulder. The acromion projected and the deltoid was flat 
below it. However, the elbow did not project from the side ; and though 
motion of the shoulder was painful, yet it could be moved more easily 
than is usually the case in dislocation. The neck of the humerus was 
certainly not broken. When the arm was raised to a right angle with 
the scapula and pulled outwards from the elbow, the head of the bone 
seemed to be restored to its place. On lowering the elbow again the 
appearance of the shoulder was the same as at first. On carefully ex- 
amining the outside of the head of the humerus I found the injury to 
consist in fracture and separation of the greater tubercle 

' Atlas, plate 22, figs. 5 and 6. 

2 Dislocations and Fractures, edited by Bransby Cooper, American edition, p. 378, 
Case 258.. 



FRACTURES OF THE TUBEROSITIES. 363 

The fracture united favorably ; but for a long time the patient had some 
difficulty in carrying the arm backwards." 

R. W. Smith 1 reported two additional cases, in one of which the nature 
of the injury was discovered at the post-mortem examination many years 
after it was received, and he was the first to call especial attention to 
the subject. He attributed its production to direct violence received 
upon the point of the shoulder and breaking off the tuberosity by direct 
action, and he attributed the displacement inward of the head to the 
action of the subscapular and of the anterior portion of the deltoid 
muscles no longer opposed by those attached to the greater tuberosity. 
Moreover, as the latter fragment is drawn upward and outward at the 
same time that the head is drawn inward the diameter of the shoulder 
appears to be much increased. 

In both of Smith's cases the head of the humerus was below and 
somewhat on the inner side of the coracoid process, and the only reasons, 
apparently, for not calling it a dislocation were that the capsule was un- 
to rn in the one examined after death, that the elbow could be brought 
to the side, and that the deformity recurred easily. I do not think, how- 
ever, that the simple separation of the tuberosity with its attached mus- 
cles would explain the occurrence of this displacement immediately after 
the accident; time would be required for the muscles to retract and to 
overcome the resistance of the capsule. It seems to me much more pro- 
bable that the violence, which in both the cases observed clinically was 
severe — a fall dow T n a staircase in one, and from the top of a three-story 
house in the other, caused a partial, perhaps, even a complete disloca- 
tion with separation of the tuberosity, and that the resultant laxity of 
the capsule and loss of support on the outer side were responsible for 
the easy recurrence of the displacement. The fact that the capsule was 
found untorn many years afterwards, is not a proof that dislocation had 
taken place. I observed a case of recent dislocation of the shoulder into 
the axilla, and showed the specimen to the New York Surgical Society, 
in November, 1880, in which the capsule was untorn ; the symptoms were 
well marked and characteristic, and the upper facet of the greater tuber- 
osity was broken off. 

Gurlt quotes a case of supposed fracture of the tuberosity by muscular 
action, in which the symptoms were extreme passive mobility at the 
shoulder, complete loss of voluntary outward rotation, and partial loss of 
voluntary elevation of the arm. If the arm was rotated vigorously and 
the ear laid upon the patient's shoulder, crepitation could be heard. 
Four weeks later the corresponding muscles were still powerless and 
atrophied. The patient was a muscular youth of twenty years, and the 
lesion was produced by an effort to throw a snow-ball with force ; something 
was heard to crack and the arm fell powerless. The only mention of 
displacement in the case is that the patient's brother, a physician, thought 
the arm was dislocated and " made a sort of reduction." 

In April, 1881, I saw at the Presbyterian Hospital a youth of 19 
years, who had been injured and admitted the preceding day. I copy 
the following notes from a record I made at the time. He said that 

1 Loc. cit., p. 176. 



364 FRACTURES OF THE HUMERUS. 

"while holding the bridle of a horse in his right hand the animal reared, 
and as he came down his breast struck against the patient's left forearm 
which was held transversely before his face in protection, and threw him 
to the ground. The left shoulder was somewhat swollen, but presented 
no other deformity ; there was an ecchymosis at the lower border of the 
tendon of the pectoralis major ; crepitation high up in the shoulder ob- 
tained by grasping the head of the bone between the thumb and fingers 
and moving them ; voluntary abduction possible ; voluntary external 
rotation impossible ; the weight of the body can be borne upon the elbow, 
the lesser tuberosity can be felt to move with the shaft when the arm is 
rotated, and there is pain on pressure over the greater tuberosity. I 
inserted an insect- pin in front over the bicipital groove ; it passed straight 
backward its full length, evidently passing between two bony surfaces, 
and by pressing its point against the inner one and rotating the arm I 
determined the continuity of this surface with the shaft. My diagnosis 
was fracture of the greater tuberosity by muscular action, by outward 
rotation of the arm in the effort to ward off the descending body of the 
horse. 

The man was discharged at his own request twelve days after the ac- 
cident. Dr. Stickler, the house surgeon, examined him six months 
afterwards, and told me that he found the breadth of the shoulder a little 
greater, slight displacement of the tuberosity upward and outward, and 
a depression between the tubercle and the head of the bone in front more 
marked than on the other side. There seemed to be some diminution of 
the power of outward rotation. The patient complained of some " loss 
of power at the point of fracture" when lifting any considerable weight 
in the hand, or when pulling upon anything above and behind his head. 

These two cases show that fracture of the outer tuberosity is not neces- 
sarily followed by displacement inwards of the head of the bone. The 
reason of the difference in the two sets of cases may lie in the persist- 
ence of some of the periosteal or tendinous attachments in the latter or 
in the simultaneous traumatic dislocation which I have suggested as pos- 
sible in the former. 

The following two cases taken from Gurlt's list of partial fractures are 
confirmatory to the extent of showing that the loss of the restraint of 
the supra- and infra-spinatus muscles alone does not lead to the displace- 
ment ; and the direction of the teres minor is such that it can offer but 
little opposition to the contraction of the pectoralis major and anterior 
fibres of the deltoid. 

I. 1 It was found by chance at an autopsy that the portion of the 
greater tuberosity to which the tendons of the supra- and infra-spinatus 
muscles were attached was broken off, a portion of the fragment remain- 
ing in the tendon, the rest having been absorbed. The tendon of the 
teres minor was in its normal position ; that of the subscapularis partly, 
and that of the long head of the biceps completely, torn across. The 
cavity of the joint was uninjured, the clavicle was broken. 

2. A man 46 years old dislocated his shoulder into the axilla by fall- 
ing out of bed. Reduction was made by Mothe's method. Three months 

1 Dundas Key, in Lancet, 1844, ii. p. 198. 



SEPARATION OF THE EPIPHYSIS 



365 



afterwards the patient died of apoplexy, having made use of the arm for 
some time. The portion of the greater tuberosity to which the supra- 
spinatus was attached was found broken off. 

And in the two following cases of total separation no mention is made 
of displacement inward or of recurrence of the dislocation. 

Malgaigne 1 treated a man 83 years old who had received an intra- 
coracoid dislocation, and died exhausted on the tenth day. The greater 
tuberosity was torn off, broken into two pieces, and drawn back under 
the acromion. The tendon of the biceps had escaped from its torn sheath, 
and the capsule was separated on the inner side from the entire extent 
of the border of the glenoid cavity, was torn below and on the outer side, 
and was adherent to the humerus only at the insertion of the teres minor. 

He quotes 2 also a case observed by Blandin, a man dying twenty-five 
days after the reduction of a dislocation forwards of the humerus with 
fracture of the greater tuberosity. 

The line of fracture usually runs along the sulcus marking the ana- 
tomical neck at the part where it adjoins the tuberosity and down the 
bicipital groove, sometimes liberating the long tendon of the biceps from 
its sheath, and allowing it to slip in between the fractured surfaces. If 
the separation is complete the fragment is drawn upward and backward, 
if incomplete, that is, if the periosteum remains untorn on the side of 
the fragment adjoining the diaphysis, new bone fills up the lower part 
of the gap, and the upper part of the fragment stands out at a distance 
from the surface from which it has been torn, 
as in figure 192. When union takes place 
it is almost always bony. 

Fractures of the lesser tuberosity are ex- 
tremely rare. Gurlt collected only three 
cases, two of them accompanying dislocation 
upward of the shoulder, the third a specimen 
in the pathological collection at Giessen 
without history. In each of the first two 
cases a small hard lump could be felt on the 
inner side of the head of the humerus, not 
moving with the movements of the arm. In 
one case it was excised three weeks after the 
accident, in the other the head of the humerus 
was excised after the dislocation had remained 
unreduced for three months. 

d. Separation of the Epiphysis. — The 
upper epiphysis of the humerus comprises the 
head and the tuberosities. The epiphyseal 
line runs upward and outward along the lower 
and inner half of the anatomical neck and 
then transversely under the tuberosities to the outer edge, passing above 
the insertion of the teres minor. Its centre is higher than its edge, so 
that the shaft terminates above in a low cone or wedge, with, of course, a 
corresponding hollow on the under surface of the epiphysis. This cone 



Fig. 192. 




Fracture of the greater tuberosity 
of the humerus united. 



1 Luxations, p. 513. 



2 Loc. cit., p. 57. 



366 FRACTURES OF THE HUMERUS. 

is very low in early life, and its height increases as the individual grows 
older, until ossification takes place, usually by the 20th year, but some- 
times as late as the 25th. The subscapular, supra-spinatus and infra- 
spinatus muscles are attached to the epiphysis, so that this fracture is in 
many respects identical with fracture through the surgical neck. 

This lesion has been observed at all ages between the moment of 
birth and the age of 19 years. In a considerable number of the re- 
corded cases, it was produced by the efforts of the midwife or physician 
to hasten delivery by drawing upon the presenting arm, or with the 
finger hooked into the axilla, or to bring down the arm from the side of 
the head when the legs and body were already delivered. In young 
children it has been caused by falls, and by violently drawing the arm 
upward and outward ; in the older cases it has been the result commonly 
of extreme violence, a fall from a height upon the shoulder, or having 
the arm caught m a revolving wheel. 

The cases are not very numerous in w T hich a direct examination has 
been made of the seat of fracture. Gurlt collected three cases in which 
the injury was caused during delivery, one each in children aged 4, 11, 
and 15 years, and a specimen obtained three years after the injury. In 
two of the first three the details are lacking ; in the third the fracture 
appears to have followed the line of junction with the shaft very accu- 
rately ; in one of the other three the fracture was compound, and the 
end of the diaphysis covered with a thin bluish layer of cartilage pro- 
jected through the wound ; in the remaining two there was some splinter- 
ing, and the periosteum was torn from the diaphysis to a considerable 
extent, and remained attached to the epiphysis like a sleeve or fringe. 
In the last case the epiphysis had united with the neck of the scapula, 
and a new joint had formed at the line of fracture. In two of the cases 
it is mentioned that the capsule was torn. 

The surfaces of fracture may preserve their relations to each other, or 
they may be separated from each other entirely, or in part. In one 
case the displacement was very slight, and appears to have been of the 
lower fragment backward, but usually the lower fragment is displaced 
forward for a distance equal to about half of its diameter, as pointed 
out by Dr. E. M. Moore, 1 and shown in fig. 193, and fixed in that posi- 
. tion by the lodgment of its outer portion in the hollow of the head, 
which is inclined forward. When the transverse displacement is com- 
plete, the lower fragment is drawn upward and inward towards the cora- 
coid process, and the upper fragment is rotated by the attached scapular 
muscles, so that its under surface looks forward and outward, or, in other 
words, so that the arm, if normally continuous with it, would be nearly 
horizontal, and the elbow directed forward and outward. 

Figs. 194, 195, and 196 represent different views of the epiphyseal 
line. 

The symptoms are quite characteristic when there is any displace- 
ment, and it seems improbable that any one who is at all familiar with 
them, even if in theory alone, would make the mistake that has 
been made occasionally of supposing the injury to be a dislocation. 

1 Transactions of Am. Med. Ass., vol. xxv., 1874, p. 296. 



SEPARATION OF THE EPIPHYSIS. 



367 



The arm hangs by the side, the elbow directed slightly backward and 
outward, and on the front of the shoulder, an inch or an inch and a half 



Fig. 193. 



194. 





Separation of the upper epiphysis of the humerus ; dis- 
placement forward of the lower fragment. (Moore.) 



Upper epiphysis of the humerus at 10 
years ; separated by maceration. Outer 
side. (Moore.) 



Fig. 195. 



Fig. 196. 




Upper epiphyseal line of the humerus ; outer side. 
(R. W. Smith.) 




Section of the upper end of the humerus, 
showing the epiphyseal line. 



below the acromion, is a distinct prominence that can be recognized by 
the eye or finger (fig. 19T), the upper surface of which feels smooth 
and slightly convex ; it moves when the elbow is rotated, and Dr. Moore 



368 



FRACTURES OF THE HUMERUS 



says that if at the same time the head of the humerus is tightly grasped 
between the thumb and fingers, crepitus can be perceived. In other 
cases the prominence is near the coracoid process, and crepitus is got 
by making extension, and then pressing the lower fragment outwards. 
Finally, there is the strong tendency of the displacement to recur. 

The course of the affection is usually simple and favorable in this 
respect, that union is the rule with but little, if any, deformity, and no 
notable loss of function, for, even if the fragments unite at an angle, the 
range of motion is not interfered with appreciably. An unfavorable 
result may be due to failure of union (Hamilton reports such a case, a 

Fig. 197. 




Separation of the upper epiphysis of the humerus. (R. W. Smith.) 

child thirteen months old), to suppuration at the seat of fracture, or to 
arrest of growth by premature ossification of the cartilage or by a com- 
plete transverse displacement with lateral union. See page 52 for cases 
of arrest of growth. Esmarch 1 reports a case of extensive osteomyelitis, 
with suppuration of the joint, in a child of 5 years, following a fall upon 
the shoulder which had caused a separation of the epiphysis ; it was 
mistaken for, and treated as, a dislocation. He excised the head of the 
bone, and the upper end of the shaft, with a good result ; that is, a use- 
ful limb, with but little shortening, and a free shoulder-joint. He does 
not say how long after the operation the observation of " slight shorten- 
ing" was made, but probably it was not subsequent to the patient's dis- 

1 Langenbeck's Arcbiv, vol. xxi., 1878. 



FRACTURES OF THE SURGICAL NECK. 



369 



shortening 



doubtless became more 



charge from the hospital, and the 
marked as the patient grew older. 

Fig. 198 represents a specimen, said by R. W. Smith to be an ex- 
ample of fracture along the epiphyseal line, united by bone, with marked 
displacement of the lower fragment inward. 

Dr. Moore has been able to reduce the displacement easily by raising 
the elbow, and carrying it up as far as possible by the side of the head. 
As the upper fragment is already displaced in this direction, the poste- 
rior portion of the capsule, which is at- 
tached to it, is made tense before the elbow 
has been raised far, and arrests the further 
motion of the head ; the continuation of the 
movement is then confined to the lower 
fragment, and brings it into its original 
relations w T ith the upper one, after which 
the arm is lowered carefully and fixed. This 
is not required in all cases. 

e. Fracture of the Surgical Nec~k. — 
(Fig. 199.) This is by far the most common 
variety of fracture at the upper end of the 



199. 




Union after separation of the upper 
epiphysis of the humerus with dis- 
placement. (E. W. Smith.) 




Fracture of the surgical neck of the humerus. 



humerus ; it occurs at all ages, and may be produced by direct violence 
received upon the shoulder, or indirectly by a fall upon the hand or 
elbow. The fracture may be transverse, oblique, or comminuted, but 
the line usually is quite irregular, and the fragments not infrequently 
impacted, and fissures may run up through the head of the bone into the 
joint, although the fracture is usually entirely extra-capsular. Esmarch 1 
says that in young people fissures stop at the epiphyseal line, and that 
consequently in gunshot fractures of the shaft or surgical neck, it is not 
necessary to remove the head of the bone. 

The displacements are various. The lower fragment may penetrate 
the upper one for half an inch or even more (fig. 200), the penetration 
being always most marked on the inner side and the head appearing in 



24 



1 Loc. cit. 



370 FRAC TUBES OF THE HUMERUS. 

Fig. 200. Fig. 201. 





Fracture of the neck of the humerus with 
impaction. (Malgaigne.) 



Fracture of the surgical neck of the right humerus, 
seen from behind. 

consequence to have slipped down the 
shaft. The upper fragment is acted 
upon by the scapula muscles in a 
manner that cannot well be opposed, 
and the consequence is that it is usu- 
ally rotated outward and upward so 
that the surface of fracture looks 
forward or forward and outward and 
the lower fragment is drawn up past 
it on the inner side. Much more rarely the upper fragment is rotated 
inwards and forwards and the lower fragment lies on its outer side 
(fig. 201). The tendon of the long head of the biceps is liable to be 
torn in these extreme displacements, and in one reported case the pres- 
sure of the upper end of the lower fragment caused permanent occlusion 
of the axillary artery. 

The oblique fractures show the same varieties of displacement, and in 
addition the sharp point of the lower fragment may perforate the soft 
parts to a greater or less extent, rendering reduction difficult or making 
the fracture compound. Occasionally, but very rarely, the deltoid is 
perforated by the end of the upper fragment. 

In some cases there is no displacement, the periosteum remains untorn 
and the only symptoms are the swelling, the localized pain, crepitation, 
and more or less loss of function, but usually there is displacement of a 
kind and to a degree that make the diagnosis easy. The usual dis- 
placement of the upper end of the lower fragment inward is accompanied 
by the abduction of the elbow and a change in the direction of the long 
axis of the limb, similar to that found in dislocation, but the arm is at 
the same time shortened and movable and the upper fragment occupies 
the glenoid cavity, maintaining the roundness of the shoulder or perhaps 
exaggerating it by its own rotation outward. Incomplete perforation of 
the muscle or, especially, of the skin by the sharp end of the lower frag- 



FRACTURES OF THE SURGICAL NECK. 371 

merit is recognized by the dimpling or drawing of the surface when the 
elbow is gently rotated. Crepitation and abnormal mobility are recog- 
nized by grasping the head of the bone between the thumb and fingers 
if possible, or by laying the palm of the hand upon the shoulder and 
then rotating the elbow and moving it in different directions. Steady 
extension should be made at the same time if there is reason to suspect 
an amount of overriding that would separate the surfaces. Ecchymosis, 
spreading often to a considerable distance over the chest and down the 
arm, is the rule, and sometimes the extravasated blood is sufficient in 
amount to lift up and distend the deltoid. 

The course of the case depends very largely upon the severity of the 
injury, the extent of the fracture, and the complications that may exist 
or arise. If the displacement is slight or if it can be readily reduced 
the fracture will usually unite in the course of one and a half or two 
months without deformity or diminution of function, except, perhaps, in 
the old or rheumatic, in whom the joint may remain stiff for a long time. 
On the other hand, the displacement is sometimes irreducible and of 
such a character that after union has taken place the functions of the 
limb are found to be much interfered with by the irregular position of 
the fragments, or perhaps the joint is obliterated by the extension to it 
of the adjoining inflammation. 

I have met with the reports of two cases in which the lower fragment 
was displaced upward and forward or upward and inward to a consider- 
able height, and reduction could not be accomplished. The cases are 
those of Ledentu 1 and Lindner 2 . In the former case the patient was 
a lad 17 years old ; there was shortening to the amount of two centi- 
metres, and although the swelling was great the end of the lower frag- 
ment could be felt directly in front of the other. Elastic traction by 
India-rubber and adhesive plaster was begun on the sixth day and con- 
tinued ten days, and then an immovable apparatus was applied until the 
twenty-fifth day. The swelling had then disappeared, the bicipital 
groove could be felt at the upper end of the lower fragment, and the 
shortening was only one centimetre. Traction by pulleys failing to 
remove this the surgeon tried to obtain a false joint, but in this also he 
was unsuccessful. Consolidation became complete during the third 
month and the movements of the limb were much restricted. 

In Lindner's case the patient was 16 years old and came under ob- 
servation on the thirteenth day after the injury. The lower fragment 
was displaced upward and inward toward the coracoid process, over- 
riding the other for two inches or more. Attempts to reduce by traction 
failed, and as the movements of the limb were much restricted and the 
position of the fragments such that their union was improbable, Lind- 
ner cut down upon the bone on the twenty-third day and excised enough 
of the upper portion of the lower fragment to permit reduction. He 
found it so firmly adherent to the soft parts that he had much difficulty 
in removing it. The antiseptic method was used and the wound healed 
without incident, but at the date of the report, two months after the 

1 Bulletins de la Societe de Chirurgie, 1876, p. 132. 

2 Central blatt fur Chirurgie, 1881, p. 225. 



372 FKACTURES OF THE HUMERUS 

operation, the union of the bone was not solid. The limb, however, 
had become very useful and it was hoped that the union might yet be- 
come bony. 

Mr. Hutchinson 1 mentions a case of fracture of the surgical neck well 
below the tuberosities in a lad of 10 years, in which the lower fragment 
was displaced upward behind the upper fragment and firmly fixed in this 
position "by the bands of detached periosteum through which it had 
escaped, and which prevented its being brought even on the post-mortem 
table into accurate apposition with the other fragment. For the same 
reason we had found it difficult during life to produce crepitus." 

In a few entirely exceptional cases suppuration has taken place in 
simple fractures, apparently as the result of some complication such as 
erysipelas or septicaemia originating in another compound fracture or in 
severe bruising of the overlying soft parts. 

The course of a compound fracture of the surgical neck is of course 
exposed to the interruptions common to that class of injuries, and in ad- 
dition to the difficulties created by the thickness of the overlying soft 
parts and the proximity of the joint. The pus is likely to burrow down 
the arm and over the breast, and it is frequently necessary to remove a 
portion of the upper end of the lower fragment either because it has 
become necrosed or because its displacement cannot be overcome. 

The result is usually a good one, so far as function is concerned, even 
if some displacement or shortening persists. The most that is to be 
looked for is a certain amount of stiffness in the joint persisting for a 
longer or shorter time in the old and arthritic. Union takes place in 
from five to eight weeks. Failure of union is rare. 

Injury to the vessels or nerves seems to be almost unknown. There are 
a few recorded cases of rupture of or pressure upon the artery when the 
fracture was in the upper part of the shaft, but I have met with none 
where the fracture was plainly of the surgical neck. A case mentioned 
by Mr. Skey in the discussion on Syme's paper on axillary aneurism in 
the Med-Chirurgical Society 2 was probably one. " The patient, a woman, 
had suffered dislocation of the humerus, and eight or ten days after its 
reduction a large traumatic aneurism of the axilla presented itself. . . . 
The patient died and on examination it was found that there was a frac- 
ture of the neck of the humerus, the pointed end of the shaft having torn 
the artery across." The only case of injury to a nerve that I have met 
with is one treated in the service of Prof. Gosselin and reported by Ber- 
ger. 3 The fracture was at the surgical neck, the lower fragment was dis- 
placed upward and inward and compressed the musculo-spiral nerve, 
causing loss of sensibility in the region supplied by it and paralysis of 
the muscles to which it is distributed. The patient died of scarlet fever, 
and the compression of the nerve was demonstrated by direct examina- 
tion. 

/: Intra- or Extra- Capsular Fractures with Dislocation of the Upper 
Fragment. — Dislocation of the upper fragment is a complication which 

i Med. Times and Gazette, 1866, i. p. 248. 

2 Lancet, 1860, i. p. 445. 

3 Bulletins de la Societe Anatomique, July, 1871 ; and Minier, Fractures de l'Ex- 
tremite superieure de 1' Humerus, These de Paris, 1879. 



WITH DISLOCATION OF UPPER END. 373 

may coexist with fracture of the anatomical or surgical neck or fracture 
through the tuberosities. It is seldom, if ever, seen except in adults, 
and is the consequence of extreme violence usually acting directly upon 
the shoulder but sometimes through the elbow or hand. The mode of 
production cannot be positively known, that is, it cannot be determined 
whether the dislocation or the fracture is first produced, or whether they 
occur simultaneously. All three views have been maintained. I think 
it not improbable that in some of the cases the injury has at first been 
simply a dislocation, and that the fracture has been caused by the sur- 
geon in his attempt to reduce it. One such case is reported by Richet ; x 
in trying to reduce an old dislocation of the shoulder by traction and rota- 
tion he caused fracture of the surgical neck. The head was left under 
the clavicle, and the end of the shaft was brought back to the cavity of 
joint and fixed there. Six weeks later the patient could make some 
movements with the arm, and still later could use it almost as well as the 
other. Agncw 2 and Hamilton 3 have had a similar experience. 

The fracture may follow the anatomical neck exactly or may diverge 
from it at any point and pass through the tuberosities, or maybe entirely 
extra-capsular, and it may present any of the varieties in direction or 
comminution that have been previously mentioned in connection with the 
different fractures, and finally, it may be simple or compound. The dis- 
location is almost always into the axilla or under the coracoid process, 
occasionally backward under the spine of the scapula ; the capsule is torn 
and the relations of the fragment with the shaft sometimes very much 
altered by the rotation of the former. In a case recorded by Malgaigne 4 
the head of the bone w r as split into two pieces, the smaller of which re- 
mained in the cavity of the joint while the larger was displaced below 
and to the inner side of the coracoid process. The following two cases 
are quoted as illustrations of the rarer fracture in the recent state. 

I. 5 A hemiplegic man between 60 and TO years of age fell to the 
floor from his bed ; he died on the 12th day. At the autopsy there was 
found a fracture of the anatomical neck of the humerus on the paralyzed 
side ; the capsule was filled with synovia and partly coagulated blood, and 
the head of the bone had been displaced backward into the infra-spinous 
fossa through a rent in the posterior and outer part of the capsule, its 
articular surface was directed backward. 

2. Malgaigne 6 quotes from Lallemand a case seen by the latter on the 
38th day : the head of the bone, separated at the anatomical neck, was 
lodged under the clavicle opposite the upper border of the pectoralis 
minor and was covered by a false membrane which had already begun to 
resemble a synovial sac ; the long tendon of the biceps was divided, the 
greater tuberosity torn off and broken in two, and the shaft of the bone, 
surmounted only by the lesser tuberosity, had been drawn up to a great 
height. 

In the older cases of all kinds, those in which repair has taken place, 

1 Gazette des Hopitaux, 1860, p. 159. 2 Surgery, vol. ii. p. 65. 

3 Fractures and Disloe., 6th ed., p. 660. 4 Luxations, p. 555. 

5 Delpech, Chir. Clinique de Moutpellier, quoted by Malgaigne aud GJ-urtt, p. 696. 

6 Luxations, p. 546. 



374 



FRACTURES OF THE HUMERUS 



the head is usually found atrophied, with its articular surface directed 
forward or downward, and immobilized by fibrous or bony bonds con- 
necting it with the scapula, or reunited with the shaft and occupying an 
articular cavity of new formation. In other cases the shaft remains 
ununited, is drawn up into the articular cavity, and there forms a new 
joint with smooth surfaces, a capsule, and ligaments that are often quite 
free and useful. The following cases illustrate some of the various con- 
ditions found when the displacement has persisted for a long time. 

1. 1 In the Museum of St. Thomas's Hospital is a specimen of disloca- 
tion of the head of the humerus and fracture at the anatomical neck 
caused some years before the death of the patient by a fall from a horse. 
The head of the bone lies on the front of the neck of the scapula im- 
mediately below the coracoid process and is firmly united to both. 

2. 2 (Fig. 202.) Fracture at the anatomical neck, the head is in the 

Fig. 202. 




Fracture of the anatomical neck of the humerus, and dislocation of the head. II, the head ; C, the 
coracoid process ; A, axillary artery ; B, tendon of the biceps. 

axilla lying upon the subscapular muscle. The infra-spinatus and teres 
minor much wasted, the supra-spinatus and subscapular less so, the ten- 
don of the biceps torn and adherent to the bicipital groove. The broken 
upper extremity of the humerus was lodged in the glenoid cavity, and 
had formed there a ligamentous joint. The head of the bone had a new 
capsular ligament to which the axillary artery adhered, it was on the 
sternal side of and a little below the level of the coracoid, it was united 
to the humerus by a small process of bone but not to the scapula. 



1 Transactions Path. Soc, of London, 1861 (vol. xii.), p 198, Case 36. 

2 Sir Astley Cooper in Guy's Hosp. Rep., 1839, vol. iv. p. 275. 



WITH DISLOCATION OF THE UPPER END. 375 

3. 1 The injury was received several years before the death of the 
patient. The head of the humerus was dislocated into the axilla and 
broken from the shaft, and it remained upon the inner side of the inferior 
costa of the scapula, to which it was firmly united. The tuberosities 
were broken off with the head, and the fractured extremity (lower) of 
the neck was placed in the glenoid cavity of the scapula. The under- 
hand motions of the shoulder were restored, but the elevation of the bone 
beyond a right angle was strongly resisted, and even with difficulty could 
be accomplished in the dead bod} T . 

4. A woman 2 83 years old fell to the ground while walking. There 
was considerable swelling of the upper part of the arm, ecchymosis, 
shortening to the extent of two centimetres, crepitation. The diagnosis 
of fracture of the surgical neck of the humerus was made, and the limb 
was kept in splints until her death, more than three months afterwards, 
at which time there was apparent union. At the autopsy the head was* 
found separated at the anatomical neck, resting against the third rib, and 
connected with the cavity of the joint only by a small piece of the capsule ; 
it was rotated so that its articular surface looked forward, and it lifted 
and was covered by the brachial nerves and the artery. There was also 
a fracture of the surgical neck that had united without deformity. The 
upper end of the humerus was bound to the glenoid cavity by broad 
short bands passing from its broken surface. 

The symptoms are in part those of dislocation, in part those of frac- 
ture. The shoulder is more or less flattened, the acromion prominent, 
and the head of the bone to be felt in the axilla, bat the elbow does not 
stand out from the side as it does in a dislocation, the arm hangs down 
and the hand can be placed on the opposite shoulder. The limb is 
usually shortened, although at first it may be lengthened by the weight 
of the arm overcoming the bruised and partly paralyzed muscles, and 
then it can be lifted directly up so that its upper end occupies the cavity 
of the joint and fills out the shoulder again. Crepitation can generally 
be felt when the lesion is fresh, either by simple rotation or by com- 
bining it with traction. In an old case which I saw in consultation and 
which was supposed to be a simple dislocation, and in which vigorous 
attempts to reduce under ether had been made a few days before, it could 
be plainly seen that the axis of the limb did not run toward the round 
hard lump (apparently the head) which lay under the pectoral muscle, 
but toward a point on its outer side, the head did not share in move- 
ments communicated to the elbow, and crepitation could be perceived. 
It was thought that the efforts to reduce the dislocation had produced a 
secondary fracture. 

A man between 60 and 70 years of age fell from a loft to the floor 
in a barn, striking with his left shoulder on the floor and against a beam 
on the way. The shoulder was markedly flattened behind, and the region 
of the pectoral muscles showed a rounded prominence. The elbow stood 
out from the side and was directed backward. The raising of the arm 
showed an unusual and very painful mobility not shared by the head of 

1 Idem, p. 274. 

2 Gaz. des Hopitaux, 1851, p. 29 ; and Malgaigne, Luxations, p. 547. 



376 FRACTURES OF THE HUMERUS. 

the bone which could be felt plainly under the pectoralis major. The 
somewhat shortened arm could be lengthened by traction, and crepitation 
could be perceived. 

Reduction was accomplished by having an assistant draw the arm 
horizontally from the body while the surgeon pressed the freely movable 
head toward the joint with his thumbs. The patient was careless and 
disobedient, and the displacement recurred on the second, and again on 
the sixth clay, it was easily reduced each time and then the arm was kept 
in pasteboard splints for six weeks. The usefulness of the limb was 
completely restored. 

Malgaigne 1 saw a case which terminated in suppuration and death in two 
months. The patient was feeble-minded and could give no account of the 
manner in which the injury was received. It was thought to be a disloca- 
tion and attempts to reduce it were made. An abscess formed, and Mal- 
gaigne saw the patient two weeks before death : the presence of the head 
of the bone under the clavicle, the shortening, and the mobility indicated 
plainly a fracture of the surgical neck, but the shallowness of the sub- 
acromial depression made him think that a portion of the head still re- 
mained in the cavity of the joint. The autopsy showed a fracture of the 
anatomical neck with a comminution that included the surgical neck ; 
the fragments were united by an exuberant callus and occupied the 
greater part of the glenoid cavity. The two tuberosities had disap- 
peared, and the tendons which are attached to them were ossified. The 
head, greatly hypertrophied, was covered with prominent irregular layers 
of bone, a fibrous band had united with its broken surface, and another 
with its summit. 

In another case 2 a man 45 years old fell from his bed upon his right 
shoulder. Dislocation was recognized, extension made by three assist- 
ants, and rest in bed ordered. Eleven months afterwards the patient 
consulted Malgaigne, the shoulder was flattened but the fingers pressed 
under the acromion recognized a bony prominence covering the glenoid 
cavity and continuous with the shaft of the humerus. Behind, half an 
inch below the posterior angle of the acromion, could be felt a semi- 
globular prominence about two inches in diameter which seemed to be 
immovably attached to the edge of the glenoid cavity, and was evidently 
the head of the humerus. The upper end of the shaft was in the glenoid 
cavity and slightly movable upon it. The arm was shortened half an 
inch, the elbow barely separated from the body and without rotation. 
All attempts to increase the range of motion at the shoulder failed. 

A man 3 22 years old was kicked upon the shoulder by a horse, and 
when seen by the surgeon four weeks afterwards had been unable to use 
the arm on account of the pain and swelling. Examination showed a 
dislocation of the humerus under the coracoid process with crepitation 
and mobility that indicated probable fracture at the anatomical neck. A 
gutta percha splint was applied, and sixteen weeks later an attempt was 
made to reduce the dislocation, but without success, and crepitation was 
again perceived. A second attempt made a fortnight later was also 

1 Luxations, p. 546. 2 Malgaigne, Luxations, p. 548. 

8 Grurit, loc. cit., p. 736, Case 175. 



UPPER EXD — DIAGNOSIS. 377 

unsuccessful. The patient could raise the arm to the horizontal position 
and the muscles were not atrophied. 

A 1 man 20 years old while trying to restrain a horse was thrown down 
and dragged a short distance and received a compound fracture of the 
neck ot the humerus, the shaft projecting in the axilla, and the skin and 
muscles on the anterior portion of the limb much lacerated. Reduction 
was accomplished by raising the arm to the horizontal line and then 
bringing it down, but the upper end of the shaft lodged below the 
clavicle, where the head of the bone also was, and could not be removed. 
The wound healed with suppuration, down to a few sinuses through which 
several splinters were discharged during the following six months. Two 
years later the patient returned to have the sinuses closed. The cavity 
of the joint was empty, the head of the humerus lay under the clavicle 
and behind the pectoralis major and was necrosed, after its removal the 
sinuses healed. Mobility was good, but elevation was defective. 

Diagnosis. — It is sometimes extremely difficult to determine on ex- 
amination of a recently injured shoulder whether or not fracture has 
taken place, and after the diagnosis of fracture has been made the re- 
cognition of the variety may be even more difficult, although perhaps 
practically less important. In any case of injury to the shoulder of 
doubtful nature the surgeon's first effort should be to determine whether 
or not the head of the humerus is in its proper place, and he will do this 
by observing the direction of the long axis of the shaft and by feeling 
for the head under the acromion. If the head is found in place its con- 
tinuity or lack of continuity with the shaft is determined by grasping it 
between the thumb and fingers and rotating the elbow gently with the 
other hand, or by grasping the head with both hands while an assistant 
moves the elbow. If the head does not share in the movements there 
must be a fracture, but the converse is not equally true, for in an im- 
pacted fracture the movements of the lower fragment will be communi- 
cated to the upper one. By the manoeuvre crepitation may be produced. 
In doubtful cases where the connections or the independent mobility of 
certain parts cannot be determined by the hands alone, it may be proper 
to use acupuncture needles. The shape of the shoulder must be care- 
fully examined, the direction of the axis of the arm, and its relations to 
the supposed head of the bone noted, and the degree of mobility of the 
limb and its shortening or elongation. Pain, ecchymosis, and swelling 
are common to most injuries, but sometimes gain a diagnostic value from 
their position. 

The question to be first settled in a case of injury is whether it is a 
fracture, a dislocation, or a simple contusion, and in order to avoid the 
frequent repetitions that would otherwise be necessary I give briefly 
under the head of each injury which may be in question the signs and 
symptoms by which its diagnosis may be made. 

Dislocation (inward and downward). — Rare in children, frequent 
in adults. Shoulder flattened, acromion prominent, outer fibres of the 
deltoid straight and tense. Elbow abducted, arm rotated inward. Head 
of the humerus in the axilla or behind the pectoral muscle and con- 

1 Gurlt. p. 736, Case 176. 



378 FRACTURES OF THE HUMERUS. 

tinuous with the shaft, its absence from below the acromion recognizable 
by the depth to which the finger can be pressed. Active movements at 
the shoulder lost, passive movements greatly diminished, elbow cannot 
be brought in front of the body nor the hand placed on the opposite 
shoulder. Deformity does not reappear after reduction. Arm lengthened 
in the subglenoid, and shortened in the infra-clavicular dislocation. 

Fracture of the Neck of the Scapula. — Very rare. Arm dependent 
and slightly lengthened, elbow slightly abducted, shoulder flattened, 
acromion prominent, possibly some fulness in the axilla. Deformity 
easily overcome by pushing the arm up towards the acromion but 
returns as soon as the arm is left unsupported ; crepitation felt during 
this manoeuvre. Active movements impossible, passive movements free. 

Fracture of the Head of the Humerus. — Extremely rare, usually a 
complication of fracture of the surgical neck. No displacement or de- 
formity. Movements not greatly interfered with, crepitation possible, 
diagnosis very obscure. 

Fracture of the Anatomical Neck. — Advanced age ; uncommon ; 
position and length of arm natural, shoulder unchanged or somewhat 
flattened, head of the bone may perhaps be felt in the axilla ; crepitation 
may be either present or absent ; possibly recognizable enlargement of 
the upper end of the bone by the splitting off of the tuberosities. Move- 
ments usually free. 

Fracture of the Crreater Tuberosity. — Rare except as a complication 
of dislocation. Position of the arm natural ; upper end of the bone 
feels enlarged, and a sulcus can be felt between the tuberosities in front; 
crepitation ; movements free, active outward rotation lost. 

Separation of the Epiphysis. — Uncommon ; unknown after 18 years 
of age. The arm is directed downward, backward, and outward, but 
the elbow can be easily brought to the side ; the upper end of the shaft 
projects in front or on the inner side of the head which can be felt in its 
normal position and does not move with the shaft. Crepitation when 
reduction is made ; reduction sometimes very difficult. In other cases 
there is no displacement, and the only signs are localized pain at the 
epiphyseal line, loss of active movements, possibly crepitation and ab- 
normal mobility. 

Fracture of the Surgical Neck. — Very common, especially in elderly 
people. May be impacted ; in the young is likely to be oblique with 
projection of lower fragment. The symptoms are very variable ; the 
arm is usually shortened and the elbow somewhat abducted ; the upper 
fragment usually lies on the outer side of the lower one and is rotated 
so that its broken surface is directed outward or outward and forward ; 
the lower fragment may penetrate or completely perforate the muscles 
and skin on the inner side of the arm. Palpation shows the presence of 
the head in the joint, its separation from the shaft, and crepitation. In 
impacted fracture the displacement is much less and crepitation is slight 
or absent. In exceptional cases the upper fragment may lie on the 
inner or posterior side of the lower one. Voluntary movements lost, 
passive movements usually free but painful. Reduction difficult or im- 
possible. 

Fracture with Dislocation of Upper Fragment. — Infrequent and 
almost confined to middle or advanced life. Arm dependent and usually 



UPPER END — TREATMENT. 379 

shortened ; region of the shoulder presents the signs of dislocation ; 
upper end of lower fragment in or near the cavity of the joint; upper 
fragment can be felt in the axilla or under the coracoid process or cla- 
vicle, is usually movable and does not move with the shaft, crepitation. 
The arm is freely movable, passively, in all directions ; reduction difficult. 

For gradual displacement resembling an unreduced dislocation see 
section on fractures of the anatomical neck (p. 358). 

Treatment. — After fracture of the head or of the anatomical neck 
with or without splitting off of the tuberosities there is rarely anything 
to be done by way of reduction, and the treatment is limited to moderate 
fixation and local antiphlogistic measures. In view of the tendency of 
the head to be crowded to the inner side by the retraction of the deltoid 
and the consequent rising of the shaft, the elbow r should be left partly 
unsupported in order that the weight of the arm may be utilized as an 
extending force to oppose the retraction of the muscles. With this 
object the supporting sling should be placed under the forearm near 
the wrist. 

If the upper fragment acts as a foreign body and provokes suppura- 
tion within the joint it mast be removed by operation, and if the adjoining 
surface has become carious a formal excision will probably be required. 

After avulsion of the greater tuberosity, the displacement cannot be 
overcome by opposing the contraction of the muscles which draw the 
fragment away, because the latter is far too small and too deeply placed 
to permit efficient control over it, and the only means of bringing the 
two broken surfaces together again is to abduct the arm to an extent 
corresponding to the displacement of the fragment ; and in order to 
prevent recurrence the arm must be maintained in this position until 
union has taken place. In the simpler cases, apparently, enough of the 
periosteum remains untorn to keep the fragments from separating widely, 
and the disability that follows fibrous union with some separation is not 
enough to justify the discomforts of the restraint which the abducted 
position of the arm would entail. In the case mentioned above which 
came under my own observation the only treatment was rest with as much 
outward rotation of the arm as could be conveniently maintained by the 
patient himself, and the resultant disability was very slight. 

In the graver cases, such as those quoted from R. W. Smith, where 
the head of the bone tends to move toward the chest as in a dislocation, 
the tendency must be opposed by some restraining dressing, such as a 
pad in the axilla, or a combination of splints such as are used after frac- 
ture of the surgical neck, or by fixation of the arm as after dislocation 
wifri frequent examinations of its position during the first few days or 
until the tendency to displacement has disappeared. 

After fracture of the surgical neck or separation of epiphysis, in 
which the mechanism of displacement is the same, the indications for 
reduction are to overcome the overriding, if it exists, and the angular 
displacement due to the abduction of the upper fragment. Mention has 
been made of the method suggested by Dr. Moore for reduction after 
separation of the epiphysis, the method which consisted in making use 
of the posterior portion of the capsule to hold the upper fragment still 
while the lower one was brought into line with it by forced elevation of 



380 



FRACTURES OF THE HUMERUS. 



the elbow. The principle of the method is one that has often been made 
use of under other circumstances and is the basis of a method of reduc- 
tion after fracture of the surgical neck, viz., abduction of the arm to 
bring the fragment into line, followed, when necessary, by extension and 
coaptation. After reduction has been thus accomplished the arm must 
be lowered carefully to the body and secured with splints. In a few 
cases it has been found impossible to maintain the reduction except by 
keeping the arm abducted. In transverse or toothed fractures the re- 
tention is not difficult, especially if the fragments can be interlocked or 
slightly impacted, but in oblique fractures with the line of fracture run- 
ning downward and outward, as is common in young adults, there is 
nothing to oppose the constant tendency of the outer scapular muscles to 
abduct the fragment to which they are attached. 

The dressing in common use is a combination of lateral splints and a 
shoulder cap. The outer splint is a moulded one made of leather, paste- 
board, gutta percha, or plaster of Paris, to fit the outer half of the arm 
and shoulder, from two inches above the acromion to the outer condyle 
of the humerus (fig. 208). The inner splint may be a short moulded 
one extending from the axilla to the elbow, or a long, angular, wooden 
one reaching to the wrist (fig. 204). The splints are applied either 
directly upon the surface, or, preferably, with an interposed layer of 
sheet lint or a compress, and bound fast with a roller bandage applied 
from below upwards, and ending in a sort of spica at the shoulder. It 



Fia:. 203. 



Fig. 204. 





Moulded splint to fit 
the shoulder and arm. 



Angular internal splint. 

is not necessary that the inner splint should rise high 
in the axilla ; it is intended not to act directly upon 
the upper fragment, but only upon the lower one, 
aiding in maintaining its relations to the outer splint. 
The object of the splint is to keep the upper end of 
the lower fragment from being displaced inward ; it 
is practically powerless to prevent shortening or the 
outward rotation of the upper fragment, except by keeping the surfaces 
of a transverse or toothed fracture in contact. The outer splint is the 
effective one, because it finds a fixed point at the acromion, which enables 
it to oppose displacement inward 

If the shoulder is much swollen at first, the application of a moulded 
splint should be deferred, for the alteration in the shape of the limb, 
effected by the subsidence of the swelling, would spoil the fit and in- 
crease the chances of displacement. Under such circumstances it is 
better to keep the patient in bed, apply soothing lotions, and immobilize 
the limb meanwhile by bandages, cushions, or extension. 



UPPER END TREATMENT. 



381 



If there is a marked tendency to overriding, to a projection of the 
sharp point of the lower fragment, it must be met not by additional ban- 
dages passing under the axilla and over the top of the outer splint, or 
by lengthening the inner splint upward and filling the axilla with a pad, 
but by making continuous extension upon the limb with adhesive plaster 
and a weight and pulley, or an elastic cord. The extension should be 
made towards the foot of the bed at an angle of from 80° to 45° with the 
long axis of the body, and the arm should be supported upon cushions 
or sand-bags. Counter-extension, if necessary, is made by a cord, one 
end of which is fastened to the head of the bed, and the other to strips 
of adhesive plaster on the breast and back. 

When the patient is allowed to walk about, the forearm should be sup- 
ported across the chest by a scarf or sling passing under the wrist, and 
leaving the elbow unsupported in order that its weight may make exten- 
sion. It may sometimes be desirable to increase this extension by sus- 
pending a weight from the elbow. I have done this with advantage in 
fractures of the shaft. 

Some surgeons advise that the hand and forearm should be bandaged 
to prevent swelling, others think it entirely unnecessary. The need 
seems to vary with the different cases. 

Erichsen recommends, as a very convenient dressing, a leather splint 
about two feet long and six inches broad, bent upon itself in the middle, 
so that one-half rests against the side of the chest, and the other half 
against the inside of the injured arm ; the angle formed by the band 
should be rounded and pressed well up into the axilla. This may be a 
useful addition to the outer splint, but I do not consider it advisable to 
oppose displacement inwards by direct pressure upon the projecting 
fragment. 

When the upper fragment is rotated outward and abducted, and can- 
not be brought back into line, the arm must be fixed in the abducted 
position which corresponds to that 
of the upper fragment. A rectan- 
gular splint has been used success- 
fully in such cases, one portion 
resting against the side of the 
chest, the other supporting the 
arm. Middeldorpf's triangle (fig. 
205), which fixes the arm in a posi- 
tion of partial abduction, is recom- 
mended by the German surgeons. 

In compound fracture with open- 
ing of the joint (usually gunshot), 
loose fragments should be removed, 
and primary excision of the joint is 
to be preferred to disarticulation, if 
the main vessels and nerves are 
uninjured. Conservative treatment 
should be tried at first if the injury 
is not very severe, but it must be 
borne in mind that secondary ex- 
cision will probably become neces- 



Fiff. 205. 




Middledorpf's triangle for fracture. of the 
humerus. 



382 FRACTURES OF THE HUMERUS. 

sary. The subperiosteal method should be used, and the surgeon's aim 
should be to obtain a movable joint. Passive motion should be begun 
after excision as soon as the wound has ceased to be sensitive, and sup- 
puration is well established. Particular attention should be paid from 
the first to preventing stiffness of the fingers and wrist, by encouraging 
the patient to move them frequently. Immobilization should be sought 
at first by pads and cushions, or by a plaster dressing if possible ; a pad 
in the axilla and one behind the upper part of the arm will prove useful. 

Compound fractures not involving the joint are to be treated on the 
same principles as fractures of the shaft of the bone. Their especial 
possible complication is extension of the inflammation to the shoulder- 
joint with all its important, immediate, and remote consequences. 

In fractures complicated by dislocation of the upper fragment the in- 
dication is to reduce the dislocation under ether at once, if possible. 
There are a number of cases on record in which this has been done suc- 
cessfully by placing the thumb against the head of the bone and the 
fingers upon the outer border of the acromion, and forcing the former 
back into place. The complete muscular relaxation of anaesthesia is very 
useful and may be absolutely necessary in this reduction, for although 
the desired end has been attained without it, the failures were so numer- 
ous formerly that the older writers usually spoke of the displacement as 
irreducible. The arm should be held in the horizontal abducted position 
during the attempt, and gentle traction may be made upon it at the same 
time, in order that it may accompany the head in its change of place. 
This attempt should be made in every case as soon as the exact condition 
of the parts is ascertained, as soon, that is, as it becomes known that the 
injury is a fracture with dislocation. No time should be lost in waiting 
for the swelling and inflammation to subside, and, on the other hand, the 
effort should not be unduly prolonged. 

If the attempt fails there still remains the- choice between trying to 
reduce the dislocation after the fracture has consolidated, and seeking to 
get a useful false joint at the seat of fracture. The recorded examples 
of the former are neither numerous nor encouraging, failure appears to 
have been the rule, death was caused once, and in two cases the effort 
was successful. One of these two was reported by Warren, of Boston, 
the other was treated in Yon Langenbeck's clinic at Berlin. 

In Warren's case 1 the patient was a young man, and an attempt to 
reduce the dislocation immediately after the accident that had caused it 
failed. Consolidation took place in four weeks, the attempt was then 
renewed and was successful in half an hour. 

In Von Langenbeck's case 2 the patient was 42 years old, and had 
broken his humerus by falling from a chair four weeks before he was 
admitted to the hospital. At this time the arm was abducted, the 
shoulder flattened, the acromion prominent, and the head of the humerus 
could be felt under the pectoral muscle. The diagnosis of dislocation 
was made, and the coexistence of a fracture discovered only during an 
attempt at reduction. The limb was then placed in splints, and eleven 
weeks afterwards the attempt was renewed with success. 

i Boston Med. and Surg. Journal, 1828, vol. i. p. 12. 
2 Gurlt, loc. cit., vol. ii. p. 735, Case 172. 



UPPER END — TREATMENT. 383 

The fatal case 1 was also in Yon Langenbeck's clinic. A sailor, 17 
years old, was thrown against the side of the vessel during a storm, and 
injured his shoulder so that he was unable to use his arm. Three weeks 
afterwards he sought treatment in England ; the injury was supposed to 
be a dislocation and eight attempts to reduce it were made in two dif- 
ferent hospitals, with the aid of chloroform and pulleys. Eight weeks 
after the accident he was admitted to Von Langenbeck's wards ; the 
shoulder was flattened, the acromion prominent, the head of the humerus 
to be felt through the axilla under the coracoid process ; the arm was 
slightly abducted, movements limited and painful. 

Three unsuccessful attempts to reduce the dislocation were made in 
ten days, and were followed by high fever, occasional delirium, and great 
swelling of the arm ; an incision which let out a quantity of thick, tarry 
blood was made just below the joint, and the patient died seventeen 
days after admission. The autopsy showed fracture along the epiphyseal 
line and separation of the greater tuberosity ; the lesser tuberosity had 
disappeared by absorption, and osteophytes had formed upon the shaft 
and the greater tuberosity. The fragments occupied a large cavity ex- 
tending from the clavicle to the axilla and filled with coagulated blood, 
which had escaped into it from the torn cephalic vein. 

The remaining alternative, that of seeking to create a useful false joint 
at the seat of fracture, may be adopted after the other attempts have 
failed, or early in the progress of the case if there seems no reasonable 
prospect of getting the head of the bone back into its cavity. The fol- 
lowing case observed and reported by Sir Astley Coopei 2 shows how 
useful such a joint may be. 

A man was thrown from a horse and received an injury of his shoulder 
which was thought to be a dislocation and was reduced. Five weeks 
afterwards Sir Astley Cooper found the head of the humerus in the 
axilla. The arm was useful for all purposes to which the dependent 
position was suitable, but could not be raised either actively or passively 
because of pain. Its mobility became much increased afterwards. At 
the autopsy many years later the head was found behind the coracoid 
process firmly united to the inner surface of the scapula, while the 
shaft of the bone with the attached tubercles occupied the cavity of the 
joint. 

In a case quoted by GurU 3 the condition of the parts several weeks 
after fracture of the neck of the humerus with dislocation was such 
(failure of union and irritation of the soft parts) that the surgeon exposed 
and removed a considerable portion of the upper end of the lower frag- 
ment. The arm became very useful. 

Excision of the upper end of the lower fragment has also been done 
in a few T cases of vicious union, for the relief of pain and increase of 
the movements of the arm ; and in one case of fracture with overlooked 
dislocation, the head of the bone was removed a year or two after the 
accident and a good result obtained. In another, reported by Vogt, 4 a 

1 Gnrlt, loc. cit., vol. ii. p. 698, Case 10]. 

2 Guy's Hospital Reports, 1839, p. 273, Case 1. 

3 Loc. cit., vol. ii. p. 731, Case 156. 

4 Deutsche Zeitschrift fur Chirurgie, vol. vii., 1876-7, p. 152. 



384 



FRACTURES OF THE HUMERUS. 



girl 11 years old had lost the use of and sensation in the arm in conse- 
quence of a fracture of the surgical neck of the humerus resulting in 
pseudarthrosis and large callus. He excised the upper part of the 
humerus, but the restoration of function was imperfect. 

It may be reasonably expected, it seems, that the usefulness of the 
limb under these circumstances will increase with time, but it appears 
desirable theoretically that the decision to try for a false joint should be 
reached as promptly as possible, before firm union shall have taken 
place between the fragments, and in order to bring the lower fragment 
as nearly as possible into the cavity of the joint. 



Fig. 206. 



2. Fractures of the Shaft of the Humerus. 

All the varieties of fracture which may occur in long bones are con- 
tained among those of the shaft of the humerus. A remarkable and 
unique example of longitudinal fracture extending the 
entire length of the bone was quoted in Chapter II. (p. 
47), and Gurlt gives two of exceptionally long fissures, 
beginning in the one case at the condyles and ending at 
the insertion of the deltoid, and extending in the other 
from the upper border of the greater tuberosity to the 
lower fourth of the shaft. Incomplete or partial frac- 
tures are extremely rare. 

All the forms of displacement common to fractures of 
long bones are also found here, and no one deserves men- 
tion as of exceptional occurrence and importance. The 
character of the displacement seems to depend largely 
upon the fracturing force, and much less upon the con- 
tractions of the muscles than has been asserted by some 
writers. Malgaigne asserts that the displacement in 
fractures caused by muscular action is slight, and the 
statement has been accepted and repeated by subsequent 
writers. 

Double fractures of the same bone are very rare ; men- 
tion has been made in Chapter II. of one reported by 
Sir Astley Cooper, and another is described and pictured 
in Malgaigne's Atlas, Plates VI. and VII. Simulta- 
neous fracture of both humeri has been caused in one 
case by epileptic convulsions, and in others by external 
violence. Gurlt quotes a case from Mauquest de la Motte who saw in 
1689 a boy 9 or 10 years old who had broken both his arms in playing 
with another boy, the left one above the elbow, the right one three or 
four finger breadths below its head. He was watched constantly by 
two maidservants, alternating with each other, and recovered in three 
weeks without a trace of displacement or deformity. In the Museum of 
Bellevue Hospital, N. Y., there is a specimen of partly united double 
or treble fracture taken from the body of a woman whose bones had be- 
come so friable during the few months preceding her death that they 
broke under the slightest causes. 

Among the injuries which may be associated with the fracture are 



Fissure of the 
humerus. (Gurlt.) 



FRACTURES OF THE SHAFT. 385 

dislocation at the shoulder, laceration of the soft parts, and contusion or 
rupture of bloodvessels or nerves. The latter deserve especial attention 
because of the gangrene of the limb or the paralysis which may result 
and may be attributed to negligence in the treatment. The brachial 
artery or vein or both may be so crushed and bruised by direct violence, 
as in the passage across the limb of the wheel of a heavily laden wagon 
or railway car, that a thrombus forms immediately within it and arrests 
the circulation ; or, more rarely, the injury to the vessel may be caused 
by the sharp edge of a displaced fragment, or the vessel may be 
stretched across the fragment in such a way as to be occluded by 
pressure. 

A very few cases have been reported in which the injury to the 
artery has resulted in the formation of an aneurism. Thus, Laurent 1 
reports an unpublished case treated by Velpeau : A lad 1 years old 
broke his humerus in the middle by a fall from an ass. The next day 
the surgeon noticed at the level of the fracture a tumor as large as a 
walnut with expansive pulsation and distinct bruit. Velpeau and Richet 
were called in consultation and immediately tied the artery above and 
below the tumor without opening the sac. Recovery was complete. 

Another case is quoted by the same writer from John and Charles 
Bell {Principles of Surgery, vol. iv. p. 407), but it was observed very 
incompletely. The patient was a woman 50 years old, and the fracture 
apparently was caused by direct violence. She survived eight months ; 
the shaft of the bone was almost entirely absorbed, and its periosteal 
sheath was adherent to the inner surface of the aneurismal sac. 

The principal nerve trunks maybe injured in like manner; and in 
addition the musculo-spiral nerve, which is particularly exposed to injury 
by its close relations to the bone, may be compressed by slipping in 
between the fragments or by inclusion in the callus. 

The causes of fracture are external violence and muscular action ; a 
variety of the former which is exceptionally frequent in this region is 
that exerted during parturition in the manipulations of the accoucheur 
or by the contractions of the uterus, the latter breaking the bone either 
as they force it past the fixed parts of the mother or possibly by their 
own direct action upon it. Fractures by muscular action are much more 
frequent in the humerus than in any other bone, and the efforts which 
have produced it have not always been very great. Illustrative exam- 
ples are given in Chapter IV. Fractures by external violence are 
direct or indirect, the latter being commonly produced by falls upon the 
hand. Exceptional causes have been observed, such as that in the case 
reported by Lonsdale of a man 24 years old who broke his humerus at 
the junction of the lower and middle thirds by striking a man with his 
fist, and in several others by the effort to reduce an old dislocation. 

Compound fractures have no anatomical peculiarities that require 
mention here. Gurlt collected five remarkable cases of almost complete 
severance of the arm by a blow with an axe or sabre, all of which re- 
covered with preservation of the limb. In all the wound was upon the 
outer and anterior aspect of the limb. 

1 Des AneVrvsmes compliquant les Fractures. These de Paris, 1874. 
25 



386 FRACTURES OF THE HUMERUS. 

The symptoms are the usual ones : abnormal mobility, crepitation, 
loss of power, pain, and more or less displacement and deformity. Im- 
portant complications, such as coincident dislocation and injury of the 
artery or nerve, are accompanied by special symptoms. Those of the 
former are the local ones of dislocation, lacking only the characteristic 
changes in the position of the elbow and lower part of the arm, which are 
here modified by the fracture. Injury to the artery is indicated by ab- 
sence or weakness of the radial pulse, either immediately after the acci- 
dent or beginning after the lapse of a few hours. An example of gradual 
occlusion of the brachial artery by a firm clot followed by gangrene of 
the limb was quoted from Stromeyer in Chapter VII. In other cases 
the symptoms have appeared gradually, the pulse becoming weak and 
finally disappearing, the fingers and hand numb and cold, the surface 
bluish and livid, and direct examination of the parts after amputation or 
death has shown a clot occupying a larger or shorter portion of the 
artery, sometimes firm, pale, and adherent, sometimes dark and soft. 

Injury of a nerve is shown by paralysis, loss of sensation, or hyper- 
esthesia in the parts supplied by it, manifesting itself immediately after 
the injury, or only after the consolidation of the fracture and the re- 
moval of the dressings. Paralysis or loss of sensation indicates division 
or destruction of the nerve ; hyperesthesia indicates irritation, usually 
by pressure. 

A simple fracture in an adult, running its course without complica- 
tions, will be solidly reunited in from four to six weeks, and in three or 
four weeks in children. The possible complications are inflammation 
and delayed union ; the former is sometimes quite marked, ending even 
in suppuration and partial necrosis, and the latter as has been stated 
elsewhere, is of much more frequent occurrence in the humerus than in 
any other bone. The general and local causes that lead to delay in a 
failure of union have been discussed elsewhere. It is held by many that 
the special reason in the case of the humerus is to be sought in defective 
immobilization of the fragments, and Dr. Hamilton has recommended 
that the limb should be dressed with the elbow extended, in order to 
secure better fixation. When the elbow is bent at a right angle any 
vertical movement of the hand or forearm is likely to cause horizontal 
movement of the lower fragment on the upper one, and lateral splints 
cannot be fitted accurately or snugly enough to prevent it. 

When the fracture is near one or the other end the movements of the 
corresponding joint may be limited by the mechanical effects of an un- 
reduced displacement, as when the upper fragment slips down in front of 
the elbow, or entirely abolished by ankylosis resulting from an exuberant 
callus or the ossification of portions of the capsule. 

The prognosis is relatively favorable; the shortening, according to 
Hamilton, will average about half an inch in those cases in which any 
results, and is of no practical importance since it produces no disability 
and is not noticeable as a deformity. 

Treatment. — In making reduction the forearm should be flexed and 
extension made by drawing upon it or the condyles while counter ex- 
tension is supplied, if necessary, by an assistant with a band under the 
axilla, or grasping the shoulder. Gradual extension by weight, or by 



FRACTURES OF THE SHAFT. 



387 



an elastic cord, may be- necessary in some cases. The treatment in frac- 
tures of the upper two-thirds is essentially the same as in fractures of 
the surgical neck ; rest in bed, with permanent extension, and the limb 
supported upon cushions, may be required at first, and the same combi- 
nation of external and internal moulded splints will be found useful. 
The plaster of Paris bandage is in very common use and furnishes good 
results, but it needs careful watching at first, both to detect displacement 
and to prevent strangulation of the limb. It should be carried from 
the hand to the shoulder and may include a few spica turns over the 
shoulder and about the chest to aid immobilization and oppose the pro- 
duction of overriding by retraction of the muscles. It is convenient to 
have the forearm flexed and supported by a sling, and if the dressing is 
properly made and solid, there is, I think, no danger of undue mobility 
at the seat of fracture. The plaster dressing is, in this respect, much 
more secure than any made of simple splints, and renders unnecessary 
the precaution recommended by Dr. Hamilton of dressing the limb with 
the forearm in the extended position. 

I have found it desirable in cases of fracture by direct violence, 
especially in women and the alcoholic, to keep the patient in bed and the 
limb supported upon cushions with moderate permanent elastic extension 
for about a week, or until the danger of acute inflammatory complica- 
tions had passed, and then to put it up in plaster. Stromeyer's cushion, 
designed particularly for the treatment of compound fractures of the 
humerus, is very useful as a support, while extension is made. It is in 
the form of a pyramid constructed upon a triangular base (fig. 207) the 

Fig. 207. 




Stromeyer's axillary cushion. 



long lines of which are from twelve to fifteen inches in length. It is made 
of stout muslin or duck, filled with hair or bran, and firm enough to keep 
its shape under pressure. 1 have found it advantageous to make the 
upper end rather more blunt than as shown in the figure. It is secured 
in place (fig. 208) by tying the upper pair of straps about the opposite 



FRACTURES OF THE HUMERUS. 



Fig. 208. 




Stromeyer's cushion. 



shoulder and the lower pair about the waist. It, can be used also 
temporarily in the place of a splint during the first few days while the 
patient is not confined to the bed, and while the surgeon is waiting 

for a swelling to subside ; the wrist 
alone should be supported in a sling, 
in order that the weight of the elbow 
may make the necessary extension. 

If the fracture has been neglected 
for some time, or if for any other 
reason shortening has occurred and 
cannot be reduced by ordinary means, 
additional extension can be made by 
suspending a weight from the arm 
while the patient sits up or moves 
about. I was able in one case to 
overcome almost completely by this means shortening to the amount 
of nearly two inches in the fourth week, using a weight of ten pounds. 

It has been thought by some that a cause of failure of union is to be 
found in longitudinal separation of the fragments by overextension due 
to the weight of the limb alone. This explanation seems improbable, 
except in the case of the weak and feeble whose muscles may have lost 
most of their power, but such a separation might be obtained by force, 
and preserved either by permanent extension or by splints. Dr. Hamil- 
ton mentions a case in which he obtained union with an increase in the 
length of the limb amounting to half an inch. If the observation was 
correct, and if the limbs were originally of equal length, the lengthen- 
ing must have been obtained by overextension, but the possibility of a 
pre-existing inequality in the length of the limbs weakens the value of 
the inference. 

Care must be taken in applying any dressing or splint to restore and 
preserve the normal relations of the two fragments, especially with ref- 
erence to rotatory displacement. The best guide for this purpose is to 
be found in the outer condyle and the greater tuberosity, since an 
imaginary line drawn from one to the other when they are in place is 
parallel to the axis of the bone. 

In the treatment of compound fractures of the humerus the general 
principles laid down in the chapter on treatment are to be followed. In 
the case of a small wound due to perforation by a fragment an occlu- 
clent dressing will often convert the fracture promptly into a simple one. 
Jonathan Hutchinson 1 recommends strongly that the ends of the bone 
should be resected whenever the opportunity offers. He says " the 
more you take, within reasonable limits, the easier will be the subse- 
quent treatment and the better the ultimate result. But you must leave 
the periosteum/' This advice certainly needs qualification. It is based 
upon the idea that the tendency to shortening cannot be readily over- 
come, and that the projection of the fragments will interfere with union. 
In a transverse fracture there is no tendency to shortening after reduc- 
tion has been made, and in an oblique fracture the resection, if limited 



1 Medical Times and Gazette, 1866, i. p. 360. 



FRACTURES OF THE HUMERUS. 389 

to one fragment, would not prevent shortening, and would, on the other 
hand, interfere materially with union, because one of the surfaces would 
be oblique and the other transverse, in part at least, and their area of 
contact would be small. A better rule is to resect only when resection 
is necessary to reduction, or when some especial reason for it, other 
than the fear of displacement, exists. Stromeyer's pad will be found 
very useful during the period when fixed dressings cannot be conveniently 
worn. 

When there is reason to fear serious injury to bloodvessels or nerves 
fixed dressings and bandages should be avoided until after the limits of 
the injury have become apparent, in order that no question may arise as 
to the cause of the gangrene or sloughing, if either occurs. Reduction 
should be made as completely as possible, and the limb supported upon 
pads or cushions. 

3. Fractures of the Lower Exd of the Humerus. 

This group, like that of fractures at the upper end of the humerus, 
includes a number of varieties differing materially in character and im- 
portance, and having in common only their position near the elbow, and 
the frequent necessity and difficulty of making a differential diagnosis 
between each and the others and dislocation. A certain lack of agree- 
ment among writers, as to the sense in which some of the distinguishing 
terms are used, makes it desirable to define those that are to be here 
employed at the same time that the limits of the divisions of the main 
group are traced. These divisions are : — 

1. Frcif't ures above the Condyles. — The line of fracture crosses the ex- 
panded part of the bone above the articular surface transversely or 
obliquely, and may or may not open the articulation. 

2. Fractures of the Internal Epicondyle or Epitrochlea. — The line 
of fracture is entirely extra-articular, and the piece broken off consists 
of the whole or part of the epicondyle. And by the internal epicondyle 
or epitrochlea, is meant the whole of the projecting tuberosity that lies 
above and on the inner side of the trochlea, and part of which is devel- 
oped about a separate centre of ossification. 

3. Fractures of the External Epicondyle. — The line of fracture is 
probably extra-articular ; the fragment is very small, consisting of the 
epicondyle proper, either alone or with some of the adjoining bone. 

4. Fractures of the Interned Condyle. — In these the line of fracture 
passes from a point on the inner border of the bone above the tip of the 
epicondyle obliquely downward and outward to the articular surface. 

5. Fractures of the External Condyle. — Similar to the preceding 
variety, except that the line of fracture begins upon the outer side and 
passes downward and inward. 

6. Inter condyloid Fractures. — These are a combination of the 1st, 
4th, and 5th, the extremity being separated from the shaft and split into 
two or more pieces. 

7. Separation of the Epiphysis. — The fracture follows the line of the 
conjugal cartilage. 

8. Fracture of the Articular Process. — In this more or less of the 



390 FRACTURES OF THE HUMERUS. 

portion of bone covered by articular cartilage is broken off, the general 
direction of the line of fracture being transverse. 

9. Simultaneous Fracture of the ends of the Humerus, Radius, and 
Ulna forming the Flbow-joint. - 

1. Fractures above the Condyles. — These fractures are those 
which come next in order of position after fractures of the lower third of 
the shaft and require separate mention because of the special questions 
involved in the differential diagnosis by reason of the proximity of the 
elboAv -joint, and by the possible extension of the fracture into the joint. 
The line of fracture may be transverse or oblique, and oblique either 
from side to side or from before backward, and it may open the joint by 
crossing the olecranon or coronoid fossa or by the extension into it of a 
fissure. When the line that extends into the joint is more than a fissure 
it may not be easy to determine whether the case belongs to the first or 
to the sixth class, and the division is therefore to a certain degree arbi- 
trary. In some cases too there is, in addi- 
Fig. 209. tion to the transverse fracture, a separate 

fracture of either condyle, particularly of 
the inner one. The displacement is usually 
very notable, the most common one being 
overriding of the upper in front of the lower 
fragment combined with more or less angu- 
lar displacement (fig. 209), this overriding 
interferes with the action of the joint by 
interposing an obstacle to flexion and by 

feupra-condvloid fracture of the L ° * 

humerus. (Hutchinson.) exuberant ossification and the production 01 

fibrous bands. Figure 210 represents a 
fracture partly transverse and partly oblique without displacement, and 
figure 211 represents another in which the lower fragment is displaced 
forward and inward, and so turned as to occupy a position at right angles 
to its natural one with its articular surface directed forward ; its surface 
of fracture is in contact and united with the anterior surface of the upper 
fragment. 

In compound fractures by indirect violence the usual displacement is 
of the lower end of the upper fragment through the tissues on the an- 
terior aspect of the limb, sometimes raising and stretching the artery 
and median nerve. 

The symptoms present a considerable diversity corresponding to the 
variations in the line and extent of the fracture and the direction of the 
displacement, but as a rule the limb appears to be shortened, and the 
olecranon is often exceptionally prominent behind, so that the impression 
given by its first inspection is that the injury is a dislocation. Its true 
character appears on examination if the surgeon can recognize that the 
relations of the tip of the olecranon with the epicondyles are unchanged 
and that the normal motions of the joint are preserved. Crepitation may 
usually be obtained, but forcible extension is sometimes needed to bring 
the fractured surfaces into contact again. In all injuries about the elbow 
one of the first points to be determined is the relative position of the two 
epicondyles and the end of the olecranon, and this is most conveniently 




FRACTURES ABOVE THE CONDYLES. 



391 



done by placing the thumb and middle finger upon the epicondyles and 
the index finger upon the olecranon and noting their correspondence with 
those of the other side in the positions of flexion and extension. 



Ficj. 210. 



Fio-. 211. 





supra-condyloid fracture of the humerus. 



Supra-coudyloid fracture of the humerus ; uniou 
-with displacement. 



The treatment in simple fractures is to place the arm in a rectangular 
grooved posterior splint reaching from the shoulder to the wrist, supple- 
mented if necessary by a short anterior one upon the arm to aid in pre- 
venting projection forward of the upper fragment. Or, if the tendency 
to displacement is slight the limb may be placed in a plaster dressing. 

In compound fractures it is strongly urged by some writers that the 
bone should be freely excised in order that the subsequent treatment 
may be made easier. There can be no question as to the propriety of 
this interference when it is necessary to reduction, or when the ten- 
dency to displacement is great and not to be easily overcome, but I do 
not think it should be laid down as a formal rule of treatment to be 
followed in every case before the tendency to displacement has mani- 
fested itself to its full extent. The limb should be inspected frequently 
during the first week or fortnight with a view to correct any recurrent 
displacement, and in consideration of the exceptional importance which 
the proximity of the joint gives to displacement. I am disposed to give 
the preference to splints rather than to complete encasement in plaster. 
Under the latter displacement may occur and remain undetected until 
it is too late to apply a remedy, while the former may be so fashioned 
as to leave the joint open to frequent inspection without pain or incon- 
venience and thus enable the surgeon to obtain timely warning of the 
necessity for interference. 



2. Fractures of the Epitrochlea or Internal Epicondyle. — By 
the epitrochlea is meant all that projecting portion of bone which lies on 
the inner side and above the level of the trochlea ; its lower limit is the 
horizontal border of the bone where it projects at right angles to the 



392 



FRACTURES OF THE HUMERUS. 



Fiff. 212. 




side of the trochlea and is therefore perfectly well defined, but above it 
is continuous with the condyloid ridge and its limit must be fixed arbi- 
trarily. In its development it proceeds partly from the shaft or internal 
condyle and partly from a separate centre of ossification at its apex, to 
which part the term internal epicondyle is sometimes restricted. In the 
classification which I have adopted this group includes all extra-articu- 
lar fractures involving more or less of this projecting part of the bone 
on the inner side, and no distinction is made between those which in- 
volve the small epiphyseal portion alone or the line of 
its junction with the remainder, and those in which a 
larger piece is broken off or in which the line of frac- 
ture crosses the epiphyseal line. This latter distinc- 
tion has led to some discussion, but its interest is 
purely statistical ; practically there is no difference in 
the treatment or in the results, and furthermore the 
diagnosis (differential as between the two) cannot be 
made upon the living with anything like certainty. No 
fracture limited to the epiphysis alone or following the 
W epiphyseal junction has been verified by direct examina- 
j| % tion while recent, except as part of an extensive fracture, 
but there are many cases of fracture, especially in chil- 
dren, in which the clinical evidence has pointed strongly 
to diastasis or fractures of the epiphysis proper. Gurlt 
knows of only one specimen of united fracture ; it is 
preserved in the collection at Wurzburg and is repre- 
sented in fig. 212. The fragment includes the epitro- 
chlea and a portion of the shaft above it, and is displaced 
downward nearly an inch. 
Dr. Hamilton presented to the New York Surgical Society in 1880, 
and describes in the sixth edition of his valuable work on Fractures, 
some specimens sent to him by Dr. Zuckercandl, of Vienna, of supposed 
diastasis, or fracture outside of the epiphyseal line of both the internal 
and external epicondyles. The specimens were found in the dissecting 
room, and were without history. The one which was thought by Dr. 
Zuckercandl to show an old fracture of the internal epicondyle presented, 
as Dr. Hamilton points out, besides the supposed epicondyle displaced 
downward, the signs of a former more extensive fracture, and it must there- 
tore remain doubtful, not only whether the small displaced fragment was 
actually the epiphyseal epicondyle, but also whether its separation was 
not merely an incident in, a part of, a much more extended and im- 
portant lesion. Dr. Lange reported at the same meeting of the Society 
a case of compound fracture of the elbow in a lad, in which the main 
epiphysis was broken off, and also each epiphyseal epicondyle, the frac- 
ture following the line of the conjugal cartilage in each case. While 
such cases go to prove what can hardly be thought to need proof, that 
the epicondyle can be separated, they certainly do not deserve to be 
classed as fractures of that limited part. 

There are a few other cases which show that fracture of the epi- 
trochlea, communicating however with the joint, may accompany dislo- 
cation of the bones of the forearm backward and outward, resembling in 



Fracture of the 
internal epicon- 
dyle of the hume- 
rus (epitrochlea). 
(Gurlt.) 



FRACTURES OF THE EPIT ROCHLE A . 393 

some respects the fracture of the greater tuberosity which may accom- 
pany dislocation of the shoulder. In one case 1 ankylosis followed, ex- 
cision was done seven months afterwards, and the direct examination 
thus afforded showed the fragment lying in the olecranon fossa. Similar 
clinical cases are quoted by Gurlt. 2 The patients were 10, 16, 28, and 
38 years old. 

The first author who called attention to this variety of fracture was 
Granger, 3 in 1818. It is more common in children than in adults, al- 
though it is generally held that this apophysis is longer in the latter 
than in the former, and, therefore, theoretically more liable to fracture. 
Granger claimed that the fracture was the result of muscular action, of 
an effort made in a fall upon the hand, but Malgaigne interprets the 
facts very differently and invokes a direct cause, external violence 
exerted directly upon the apophysis. In some cases the evidence of the 
violence appears to have been complete, and the theory of the interven- 
tion of this cause seems to me to receive additional support from the 
greater frequency of the lesion in the young, those whose muscles are 
comparatively weak, and whose efforts to save themselves from injury 
are comparatively feeble. Any one who has observed a child fall must 
have noticed how thoroughly he does it, how slight and tardy the appa- 
rent effort to save himself. In one of the two cases of this injury which 
have come under my own observation everything favored the theory of 
a fracture by direct violence. The patient was a girl 13 years old Avho, 
while skating upon rollers, fell back upon the sidewalk, striking upon 
the inner side of her right elbow. She said she had felt something out 
of place after she fell and had slipped back a little lump by pressing it, 
indicating the epitrochlea as the lump. She was seen immediately after 
the accident by Dr. Keyes, who was able to grasp the epitrochlea be- 
tween his thumb and finger and move it. At his invitation, I saw the 
case the following clay, and found the region very tender and swollen, 
and occupied by a large ecchymosis. There was no interference with 
the motions of the joint. 

In the other case the mechanism was more complex. A boy, 11 years 
old, fell from a fence, striking upon the right side with his right arm 
bent under him. He was brought immediately to the Presbyterian 
Hospital ; there was no bruise, the arm was extended and could not be 
flexed, and the deformity was described by the house surgeon as a 
prominence behind on the outer side, and a depression in front in the 
flexure of the joint. It was thought to be dislocation, and was reduced 
without noise or jar by drawing the forearm gently forward. I saw 
the patient on the following day, found the joint normal in form and 
function, except that extension was incomplete and painful ; rotation of 
the forearm perfectly free and painless ; and a small hard lump, mova- 
ble with distinct crepitation, could be felt at the site of the epitrochlea ; 
its range of motion was about one-fourth of an inch when the arm was 
semi-flexed, less when it was extended. The arm was kept in a rectan- 

5 Laiigenbeck's Archiv, vol. iii. 1862. p. 31. No. 139. 

2 Loc. cit., vol. ii. p. 823, Cases 305, 306, 307, 308. 

3 Edinburgh Med. and Surg. Journal, vol. xiv. p. 196. 



394 FRACTURES OF THE HUMERUS. 

gular. splint, and the patient made a good recovery with complete range 
of motion, but the fragment united with displacement downward to the 
distance of a quarter of an inch. 

I am not sure of the character of the associated injury in this case ; 
possibly it was a partial separation of the epiphysis or of its trochlear 
portion, an accident which would render the diastasis of the epitrochlea 
easier. 

The symptoms vary somewhat with the size of the fragment, for when 
the latter is small it is held in place by the untorn portion of the muscular 
attachments which are inserted upon the adjoining portions of bone ; but 
when it is large enough to include the greater part of the attachment 
displacement takes place downward and forward in the direction of the 
muscles. If the swelling is not too great the fragment can be recognized, 
seized between the thumb and finger, and moved, usually with crepita- 
tion. As above remarked, the extent of this mobility in one of my 
cases was affected by the position of the forearm. Ecchymosis is com- 
mon, and the functions of the joint are diminished either by pain or by 
fear of exciting it. In one of Malgaigne's patients, a man 51 years old, 
the attached muscles appear to have remained for some time in a state 
of spasm or watchful contraction which greatly limited the movements of 
the forearm. 

In a few cases the ulnar nerve has been injured by the original vio- 
lence or irritated by pressure of the displaced fragment or a portion of 
callus. In three of Granger's cases there was partial paralysis of mo- 
tion and sensation in the region supplied by the ulnar nerve, and re- 
peated crops of vesicles formed upon the corresponding part of the hand 
during the two or three months following the injury. All the symptoms 
disappeared after a time. Richet 1 observed a case of fracture of the 
epitrochlea with dislocation of the elbow inward due to a fall upon the 
ice. After reduction of the dislocation the ulnar nerve was found to be 
completely paralyzed. A month later the little finger was so insensi- 
tive that the patient amused himself and amazed his playfellows by 
holding it for more than a minute in the flame of a candle. The deep 
burn which was the result took several weeks to heal, and afterwards 
sensibility returned gradually and became complete. 

Denuce 2 was consulted by a man suffering with an intense neuralgia 
of the ulnar nerve following a fall upon the elbow three months before. 
He recognized deformity of the epitrochlea, made an incision, and found 
the nerve hypertrophied and resting upon a bony prominence formed by 
the epitrochlea displaced and united in its false position. The project- 
ing part of the bone was excised, and the neuralgia ceased. 

The reaction is seldom severe, and when so, it appears to be mainly 
the result of the contusion which has caused the fracture, or possibly of 
an associated sprain. Nevertheless there is frequently mentioned in the 
recorded cases a degree of temporary limitation of the movements of the 
joint, which seems quite disproportionate to the injury ; thus, in one of 

1 Anatomie Medico-Chirurgicale, 4th ed., p. 672, note. 
8 Diet, de Med. et Chir. Pratiques, art. Coude, p. 721. 



FRACTURES OF THE EXTERNAL EPICONDYLE. 395 

Malgaigne's cases the range of motion two and a half months after the 
accident was only 60°, or about only half as great as it should be. 

The treatment is simple : immobilization of the elbow in the flexed 
position so as to relax the muscles that arise from the epitrochlea and 
thus diminish the force that tends to draw it forward and downward. It 
is of doubtful utility to attempt to keep the fragment in place by pressure 
upon it from the outside. Even if it remains displaced downward and 
forward the deformity is slight and entails no loss of function. Im- 
mobilization should be maintained until consolidation has taken place, 
the length of time necessary for which varies with the age of the patient 
and the extent of the unreduced displacement. In children, and without 
displacement, union is sufficiently firm at the end of ten days or a fort- 
night to allow splints to be laid aside and the arm to be carried in a 
sling, and in three weeks the arm may be left unsupported and free. 
Most authors recommend that passive motion should be begun during the 
second or at the beginning of the third week; but if the joint is not in- 
flamed passive motion is useless, and if it is inflamed absolute quiet is 
what it most needs. The slight movements permitted by a sling in cases 
in which the joint is not painful are sufficient to keep it from stiffening, 
and the limitations of motion which follow prolonged immobility do not 
long withstand regular exercise after the injury has been repaired. 

Quite recently Pauly 1 has removed the fragment through an incision 
on the theory that this would diminish the chance of an excessive forma- 
tion of callus. As this chance does not appear to be at all great, I think 
most surgeons will postpone operative interference until the actual need 
arises. 

3. Fractures of the External Epicoxdyle. — This is a much rarer 
accident than the preceding, and as the fragment that is broken off is 
small, and as the cause appears to be always direct violence, which is 
usually accompanied by bruising and swelling, the exact nature of the 
injury may easily pass unrecognized. An anatomical demonstration of 
the fracture has never been made, except in connection with more ex- 
tensive fractures of the elbow. Zuckercandl's supposed specimen, to 
which reference w T as made in the preceding section, appears to have been 
only an irregular deposit of bone in the external lateral ligament. In 
the discussion which followed the presentation of these specimens to the 
New York Surgical Society, Dr. McBurney said he had found in the 
dissecting room similar isolated pieces of bone resembling detached epi- 
conclyles and existing symmetrically at both elbows, a fact which makes 
the intervention of a traumatic cause extremely improbable. 

In the sense in which the term is here used the epicondyle is the small 
prominence above and on the outer side of the capitellum, composed in 
part of bone formed about a separate centre of ossification, and in part 
of the projecting portion of the shaft or condyle itself. To it are attached 
the external lateral ligament of the joint and some of the extensor muscles 
of the forearm. 

Most surgeons deny the possibility of an extra-articular fracture of 

Centralblatt fur Chirurgie, 1882, p. 157. 



396 



FRACTURES OF THE HUMERUS 



this part, and group all fractures of the region as of the external condyle. 
Anatomically speaking it is certainly possible for such a fracture to 
occur ; the epicondyle, though small, is still large enough to be broken 
in such a way that the line of fracture may lie entirely outside the joint. 
Coulon 1 quotes the following case that was under his observation during 
his internat at the Hopital Ste. Eugenie (Children's Hospital), and adds 
that Marjolin, the attending surgeon, saw similar ones every year. The 
observation is entirely clinical, and may therefore be considered not 
entirely demonstrative. 

Paul G\, 3 J years old, fell to the sidewalk from a chair on the 15th 
of October, I860, and was brought to the hospital some time after the 
accident. The right elbow was swollen and there was an ecchymosis on 
the outer side ; pressure at the ecchymosis disclosed abnormal mobility 
and crepitation, leaving no doubt of the existence of a fracture of the 
epicondyle ; the epicondyloid fragment could be grasped between two 
fingers and felt to be very small. As there was no displacement Mar- 
jolin applied no splints, but simply kept the child in bed with the arm 
upon a cushion and covered with compresses wet with tincture of arnica. 
Consolidation was complete by the 25th ; the child was allowed to go 
about with the arm in a sling, and passive motion of the joint was made. 
On the 15th of November the child left the hospital, the movements of 
the joint were complete, the epicondyle was a little larger, more rounded, 
and less prominent than the one on the other arm. The smallness of 
the fragment, and the absence of articular rigidity after consolidation 
led us to make the diagftosis of an extra-articidar fracture. Italics in 
the original. 

Gurlt 2 describes as extra-articular fractures of the external epicondyle 
two specimens preserved, the one at Giessen, the other at Berlin. In 
each the fracture has united with considerable dis- 
placement downward of the fragment which ap- 
pears in the description and figure (fig. 213) too 
large to have been entirely extra-articular. Still, 
his personal examination of the specimens was 
more likely to lead to a correct opinion of them 
than a verbal description or a figure is. 

There is little to be added. The cause must be di- 
rect violence ; the displacement must be slight and un- 
important ; the treatment, rest and soothing lotions. 

4. Fractures of the Internal Condyle. — 
This is one of the commoner, the more frequent 
varieties of fracture at the elbow, and one of the 
most important, because, beside being intraarticu- 
lar and thus exposing to the usual disabilities in- 
cidental to such fractures, it includes the part of 
the articulation which is in relation with the ulna, 
and therefore any alteration in the relations of the parts which imposes 
a mechanical obstacle to motion interferes at once with the principal 



Fig. 213. 




Fracture of the external 
epicondyle of the humerus. 

(Gurlt.) 



1 Des Fractures chez les Enfants. 

2 Loc. cit., p. 798. 



Paris, 1861, p. 143. 



FRACTURES OF THE INTERNAL CONDYLE 



397 



function of the joint. Physiologically speaking, the elbow-joint consists 
only of the humero-ulnar articulation. The association of the radius 
with it serves to increase the breadth and thereby the strength and 
solidity of the hinge, but this association is not essential to the proper 
performance of the functions, either of it or of the radius. The head of 
the radius merely rests against the humerus, while the ulna embraces its 
corresponding articular surface over an arc of nearly half a circle, and 
has in addition a central ridge running in the direction of its motion 
which fits into a corresponding groove upon the trochlea and opposes 
lateral displacement. The axis of the joint is inclined to the long axis 
of the humerus, so that when the latter hangs directly down the forearm 



Fis:. 214. 



Fig. 215. 




Showing the relations of B, the axis of the elbow- 
joint, to A, a line drawn perpendicular to the long 
axis of the humerus. (Tillaux.) 



The outward deflection of the fore- 
arm. The " carrying function." 



is directed somewhat outwardly, away from the body, at an angle that 
varies in different individuals and even in the arms of the same indi- 
vidual. This angle favors that use of the arm to which Dr. Fowler, of 
Brooklyn, gave the name of the " carrying function," since it removes 
the hand to a convenient distance from the thigh when the arm hangs 



398 



FRACTURES OF THE HUMERUS. 



Fig. 216. down with the elbow resting against the hip and the 

hand supinated. In addition this angle causes the 
direct line of transmission of a force received upon 
the ball of the hand when the elbow is fully ex- 
tended to pass through the head of the radius and 
the external condyle, as shown in figure 216, and 
not through the ulna and internal condyle. It ap- 
pears probable to me that, in consequence of this 
arrangement, many fractures of the external con- 
dyle are due to direct transmission of force in a fall 
upon the hand, and that fractures of the internal 
condyle, other than those caused by a blow upon the 
elbow, may be produced in either of two ways : 1st, 
transmission of force through the ulna, acting either 
directly in the line of its long axis, or transversely 
so as to turn the forearm laterally towards the 
inner side upon the head of the radius as a centre ; 
or, 2d, by a force acting in the opposite direction to 
that last named, turning the forearm towards the 
outer side and tearing off the internal condyle by 
means of the internal lateral ligament. In the 1st, 
the fragment would be displaced upward and back- 
ward; in the 2d, downward. I am disposed to con- 
sider the 2d one as the mechanism of those cases of 
fracture of the epitrochlea with partial dislocation 
of the forearm mentioned above. 

The loss of this divergent angle in consequence 

either of the ascent of the internal condyle or of 

the descent of the external condyle is the essential 

part of the deformity seen so frequently after u fracture of the elbow" 

and represented in fig. 217 which I take from a valuable and interesting 

paper by Dr. Oscar H. Allis 1 upon this subject. 

The line of fracture runs from a point above the epitrochlea obliquely 
downward and outward to the articular surface, crossing the olecranon 
fossa, and terminating at a variable distance from the inner edge of the 
trochlea, but usually, according to Hamilton, at the centre of the latter. 
The usual displacement is of the lower fragment upward and backward, 
and is due either to the action of the original force, or to the contraction 
of the biceps, triceps, and brachialis anticus, or, as Dr. Allis has pointed 
out, to the pressure of the bandages and splints. The ulna remains at- 
tached to the fragment by the internal lateral ligament and follows it in 
its displacement, or it prevents displacement in some cases by preserv- 
ing its own relations to the other parts of the joint, a condition which is 
undoubtedly favored greatly whenever the line of fracture passes near 
the inner edge of the trochlea and the fragment is a small one. In ex- 
ceptional cases the displacement is forward or downward. 

Dr. Markoe 2 was the first to call especial attention to the fact that 




Showing the transmis- 
sion through the external 
condyle of a force re- 
ceived upon the palm. 



1 Annals of the Anatomical and Surgical Soc. Brooklyn, Aug. 1880. 
■2 N. Y. Journal of Med., 1855, p. 382 ; and N. Y. Medical Record, 1880, vol. xviii, 
p. 118. 



FRACTURES OF THE INTERNAL CONDYLE. 



399 



with this injury there may be associated dislocation of the radius back- 
ward, that is, displacement backward of the radius, ulna, and fragment, 
these three pieces preserving their relations to each other, a complica- 
tion* that is most disastrous in its results if not promptly recognized and 



Fig. 217. 




Deformity after fracture at the lower end of the humerus. (Allis.) 

corrected. An instance of this kind was reported before Dr. Markoe 
wrote upon the subject, but it appears to have attracted no attention ; 
Gurlt (loc. cit., vol. ii. p. 820) quotes the case from Michaux. 

The symptoms are independent mobility of the condyle, crepitation, 
and displacement. The first two are obtained by grasping the condyles 
with the fingers of either hand and moving them backward and forward 
upon each other, or by grasping the lower portion of the arm with one 
hand and moving the forearm with the other. Displacement of the con- 
dyle is recognized by ascertaining its relations to the other condyle and 
the olecranon and comparing them with the known standard or with 
those of the other arm. When the forearm is fully extended a line 
joining the two epicondyles crosses the tip of the olecranon, if the parts 
are in their normal relations, and as the forearm is flexed the olecranon 
sinks below this line. If there is displacement backward there is 
marked resemblance to a dislocation in the projection of the olecranon 
when the forearm is flexed and in the disappearance of this projection 
when it is extended. Sometimes the transverse diameter of the lower 
end of the humerus is appreciably increased, but even under the most 
favorable circumstances " this is not easily recognized and the swelling 
may be sufficient to mask it completely. 

In fracture with dislocation backward of both bones the leading 
features, according to Dr. Markoe are : 1st, the resemblance to a dislo- 
cation backward ; 2d, the preservation of the relations of the internal 
condyle and the olecranon, the position of the head of the radius below 
and behind the external condyle, and the abrupt ending of the condyloid 
ridge of the humerus in a sharp projection about an inch above the joint; 
8d, the independent mobility of the fragment with crepitation ; and 4th, 
the termination of the humerus in front in a sharp small prominence. 



400 FRACTURES OF THE HUMERUS. 

The displacement is easily reduced and reproduced. The following case 
taken from Dr. Markoe's last paper on the subject is fairly typical : — 

"Michael Lee, aged 10, was admitted to the New York Hospital 
October 11, 1859. Five days before he had fallen from a ho?se, 
striking on his left side, with his arm twisted under him. Great swell- 
ing and ecchymosis took place immediately. On the 17th the swelling 
had so far subsided as to give us a chance to examine the fracture. The 
internal condyle and olecranon were in proper relation to one another, 
while the head of the radius had left the external condyle, and was 
easily felt rotating behind and to the outside of it. The whole aspect 
of the elbow was that of dislocation backward, and the end of the hume- 
rus making a rounded projection on the anterior face of the joint. The 
parts were so easily movable that it could further be distinctly made 
out that a considerable fragment of the internal condyle, broken from 
the shaft of the bone, remained attached to the olecranon and moved 
with it. The whole displacement could be easily reduced and the defor- 
mity removed, while on letting go the limb it was immediately repro- 
duced. Dr. Van Buren saw the case with me and recognized the facts 
as above stated, and without hesitation agreed with me in the diagnosis 
of fracture of the internal condyle, involving so much of the basis of 
support of the olecranon as to allow of its displacement backward to a 
sufficient extent to permit the head of the radius to be also pushed back- 
ward, as in ordinary luxation. The displacement was reduced, and the 
arm placed at an angle less than a right angle and so retained by an 
angular tin splint, a firm pad being placed on the prominent end of the 
humerus to keep it in place. On the 30th the apparatus was removed 
without my knowledge, and the young man reported that union of the 
detached fragment was firm and the joint in good shape. He was dis- 
charged December 1st without my having had an opportunity of exam- 
ining the arm." 

The following case reported by Coulon 1 may serve as an example of 
the cases not complicated by dislocation, a simple fracture extending 
through the trochlea. 

A child, four years old, was brought to the hospital two hours after 
she had fallen down a staircase. The elbow was swollen, the forearm 
slightly flexed upon the arm, the relations between the olecranon and 
epicondyles normal. Pressure upon the epitrochlea produced crepita- 
tion, but the swelling made it impossible to recognize the size of the 
fragment or the extent of the mobility. Flexion and extension were 
rendered almost impossible by the swelling and pain. The limb was 
partly flexed and fastened upon a hard cushion and treated with poul- 
tices and arnica, and on the fifth day placed in a gutta-percha splint. 
On the seventeenth day there was no longer crepitation or mobility ; 
after the twenty-first day the arm was left in a sling and forcible pas- 
sive motion was made every day. At the end of a month she left the 
hospital ; the arm could be flexed to a right angle and extended to an 
angle of 140°, the epitrochlea was displaced inward and forward, and 
the fragment could be felt to be voluminous. Two and a half months 

1 Fractures chez les Enfants, Paris, 1861, p. 159. 



FRACTURES OF THE INTERNAL CONDYLE 



401 



Fiff. 218. 



later the condition was the same, although the parents claimed to have 
made forced passive motion. 

The course of the case is usually simple and uncomplicated, the swell- 
ing and ecchymosis disappear after a few days, the fragment reunites 
with the shaft, and the process of repair is practically terminated in the 
course of four or five weeks. But the tendency to displacement, to 
reunion of the fragments in a position that interferes more or less seri- 
ously with the functions of the joint, is great, and not easily overcome ; 
and in young people there is an equally dangerous tendency, one which 
exists in all fractures near to or involving joints, to overgrowth of callus 
to an extent and in positions which may greatly restrict the movements 
of the joint. Among the displacements the one above mentioned, fig. 218, 
which consists in the elevation of the inner condyle 
and the consequent loss of the outward deflection of 
the extended forearm from the line of the arm, is to 
be especially borne in mind. 

Dr. Weir Mitchell 1 mentions a case of inflamma- 
tion of the ulnar nerve following seven years after a 
fracture thought to be of the internal condyle and 
caused by direct violence. The pain was so severe 
that the patient sought amputation. Dr. D. H. 
Agnew excised two and a half inches of the nerve 
just above the elbow with immediate and permanent 
relief of the pain. Three montlxs after the opera- 
tion motion and sensation had been completely 
restored in the region supplied by the nerve. 

The treatment consists in reduction of the dis- 
placement and of the accompanying dislocation, if 
there be one, and retention by dressings designed to 
act upon the fragment, not directly, but through the 
ulna which remains attached to it. The usual, al- 
most universal, treatment has been to fix the arm 
upon a rectangular internal lateral or posterior splint, 
and to begin passive motion not later than the third week. The results 
of this are certainly not satisfactory; union with displacement, as above 
described, is common, and more or less rigidity of the joint not infre- 
quent, and there are those who now claim, with much apparent reason, 
that these defects are, to a certain extent, the consequences of the inade- 
quate or ill-regulated support of the splint. Dr. Allis called attention 
to the subject in an impressive manner, and alleged that with a lateral 
or a posterior splint bound to the arm with a roller bandage the ulna 
and the attached condyle were not merely not held in place, but were 
actually pressed upward out of place, and thus the very defect was pro- 
duced which the surgeon sought to avoid. He claimed that the radius 
and external condyle formed the fixed point towards which the ulna and 
internal condyle were drawn by the turns of the bandage. Dr. Allis's 
explanation does not seem to be entirely satisfactory, because the ascent 
of the internal condyle is not in the direction in which the pressure of 




Fracture of the internal 
condyle of the humerus ; 
displacement upwards ; 
union. (Gurlt.) 



26 



Injuries of Nerves, 1872, p. 295. 



402 FRACTURES OF THE HUMERUS. 

an enveloping bandage would tend to force it ; the radius and ulna are 
in contact at their upper ends, and cannot there be drawn closer together, 
but if the arm is supported in a sling the support is transmitted through 
the ulna, which is the undermost part of the forearm, and necessarily 
presses it upward, so that the inclination of the axis of the elbow-joint 
is changed in the manner and with the result above described. It is 
immaterial, so far as this result is concerned, whether the splint is a pos- 
terior or a lateral one, for in the former case the ulna rests directly upon 
it, and in the latter it rests upon the turns of the bandage which binds 
them together. 

The conclusion which Dr. A His reaches is that the fracture should be 
treated with the arm in the extended position, and preferably in a 
moulded splint or immovable dressing. He employs and recommends a 
simple dressing of strips of adhesive plaster, either used alone or com- 
bined with a light, immovable dressing. In the first case he places the 
limb in an easy, natural, extended position, and covers it with strips of 
adhesive plaster applied longitudinally, each about an inch wide, and 
long enough to reach nearly from the shoulder to the wrist. Over this 
layer he applies a second similar one, and leaves both on for five or six 
weeks, seeing the case at first every day and then once a week. In the 
second method he applies three strips, one on each side and one behind, 
then a layer of cotton batting over the joint and for some distance above 
and below it, and then a roller bandage. As soon as the cotton is 
entirely covered by the bandage he smears the surface with a paste made 
of the white of two or three eggs thickened with flour, applies a second 
layer of bandage, smears that also with the paste, and finishes with a 
third layer of the bandage. He adds : " the perfection of the cure will 
depend wholly upon the natural position assumed by the limb while the 
dressing is applied. Hence, lay the patient on the back, and with both 
arms stripped take the sound arm as the guide. When the limb is 
placed supine, the thumb looking outw T ard, note that the normal [unin- 
jured^ limb is not straight, but that an obtuse angle is to be observed 
on the radial side of the elbow-joint. Observe this in the dressing, and 
if this is carefully preserved until the paste has hardened there is 
nothing to fear from displacements." 

Dr. Allis declares that this practice has yielded in his hands excellent 
results ; that is, when the dressings were removed the limbs were found free 
from deformity, and even, in the milder cases, from stiffness. The theo- 
retical grounds upon which the method rests, I believe to be entirely sound, 
and the practice to be free from objection whenever the extended posi- 
tion does not favor, as it sometimes does, dislocation of the forearm 
backward. In the extended position, with the head of the radius resting 
firmly against the capitellum, the internal condyle can be brought fully 
down by fixing the arm and drawing the wrist gently outward, and so 
long as the forearm is kept in this position the condyle cannot rise. On 
the other hand, displacement forward or backward remains easy, and I 
should be unwilling to trust to the protection supplied by two thicknesses 
of adhesive plaster, particularly since the extended arm is a much more 
awkward limb, and one that is much more exposed to accidental violence 
than a flexed one. 



FRACTURES OF THE EXTERNAL CONDYLE. 403 

I have not had sufficient experience with the method of treatment in 
the extended position to say more than that I am myself willing to make 
use of it, but that I prefer to use a moulded posterior gypsum splint, 
and a position 30° or 40° short of complete extension, in order to detect 
any tipping forward of the fragment if it should occur. This preserves 
the lateral angle, and is a better protection against chance violence ; at 
the same time the splint can be easily removed and replaced if the surgeon 
desires to make passive motion. 

I do not think early passive motion is necessary to prevent stiffness of 
the joint; and when it is painful, the pain lasting for some time, I believe 
it to be actually harmful by increasing and prolonging the inflammation. 
No harm can come from gently moving the arm once or twice daily 
through the range of motion which is easy and painless, and, on the 
other hand, no good can come, in my judgment, from forced motion or 
from any motion that excites tenderness during the first four or five 
weeks. The records of cases are filled with instances in which the joint 
has become almost or entirely rigid under treatment by passive motion, 
and then after the tenderness had ceased mobility has returned gradu- 
ally under ordinary daily use of the limb. When there is displacement 
that restricts motion mechanically, the range may sometimes be increased 
by forcing gently every day with the hands, or constantly by elastic trac- 
tion, after consolidation has begun and before it is firm, for the displaced 
fragment can thus be pressed out of the way ; but the stiffness which is 
due to peri-articular thickening or intra-articular bands is best prevented 
or diminished by rest during the inflammatory period, and will after- 
wards yield to constant regular use, or the bands may be afterwards 
forcibly broken under ether. 

If the extended position proves very inconvenient to the patient, I think 
flexion at or near a right angle could be safely substituted for it after 
the first fortnight, with the protection of a moulded splint or immovable 
dressing, because by that time the tendency to displacement, under the 
influence of the contraction of the muscles or the weight of the limb, 
would have been removed by the partial union of the fragments. In- 
deed, the principal advantage of the extended position appears to be in 
the certainty of the reduction rather than in the retention. An immo- 
vable dressing can be applied to the flexed arm in such a way that it will 
keep the parts in position and will not press unduly upon the ulna, but 
the surgeon cannot be certain that the reduction is complete. A change 
of one-fourth of an inch in the position of the condyle will in most cases 
be sufficient to destroy the outward inclination of the forearm entirely. 

In the cases complicated by dislocation of the forearm backward it 
has been found necessary to keep the elbow flexed to a right angle, or 
even a little further, in order to prevent the recurrence of the disloca- 
tion. Dr. Markoe recommends for these cases a grooved posterior splint 
with a short anterior one on the arm, and he begins passive motion in 
the third week. 

5. Fractures of the External Condyle. — These also are among 
the more frequent fractures at the elbow, and, like those of the internal 
condyle, are much more common in children than in adults. Of 29 cases 



404 FRACTURES OF THE HUMERUS. 

recorded by Hamilton all but 2 occurred in children under sixteen years 
of age. The fracture may be produced by a fall upon the hand, or by 
a fall upon the posterior and inner portion of the elbow ; in the former 
case the force is transmitted through the radius ; in the latter, in some 
cases at least, the force is received upon the olecranon or ulna, which is 
thereby driven forcibly upward and outward, splitting off the external 
condyle. Ordinarily the periosteum is not torn extensively, and the dis- 
placement is not great. Tie line of fracture, runs obliquely from the 
outer ridge of the humerus downward and inward into the joint, some- 
times extending as far inward as the middle of the trochlea. Malgaigne 
gives in his Atlas, Plates VIII. and IX., illustrations of two fractures of 
the external condyle, both old and ununited. 

Displacement may take place in any direction except inwardly, and is 
not infrequently accompanied by partial dislocation of both bones of the 
forearm outward, sometimes by that of the radius alone. Two cases of 
extreme displacement outward and upward, so that the olecranon lay 
upon the outer side of the humerus, were reported recently by Franz 
Schmitz 1 Avith drawings after dissection. The outer condyle in one was 
ununited ; flexion and extension limited to the arc between 105° and 
140°, pronation and supination perfect. A neuritis of the ulnar nerve 
had been excited by the overstretching of the nerve, and had led to 
paralysis of the corresponding muscles. The second case was found in 
the dissecting-room, with no history, and no appearance of nerve trouble. 

The radius usually preserves its relations to the condyle, but in a case 
reported by Dr. Hamilton it was displaced backward and separated 
entirely from the condyle. The displacement could be easily reduced, 
but the reduction could not be maintained, and apparently the displace- 
ment did not interfere with the functions of the joint. 

The symptoms of the fracture vary principally with the degree of the 
displacement. There are the usual symptoms, swelling, pain, ecchymosis, 
and crepitation ; the latter is obtained most readily by rotating the fore- 
arm and by pressure upon the condyle. The anatomical guides in the 
diagnosis are the same as above detailed in the other fracture : the rela- 
tions of the olecranon and epicondyles, and the position of the head of 
the radius. The latter lies normally a short distance below the external 
epicondyle. If the finger is carried directly downward from the tip of 
the epicondyle and the forearm is gently rotated the edge of the head of 
the radius can be felt very distinctly to move to and fro, and whenever 
the swelling is not so great as to mask the parts this examination will 
enable the surgeon to determine positively whether the head of the radius 
is, or is not in its proper place. As the line of fracture is oblique dis- 
placement of the fragment upward will always be also somewhat out- 
ward, and thus the transverse diameter of the lower end of the humerus 
will be increased. 

The effect of the displacement upon the normal outward deflection of 
the forearm is to increase it if the displacement is upward, and to diminish 
it if it is downward. The recorded cases indicate that the former is the 

1 Ein Beitrag zur Chirurgischen Pathologie des Ellbogengelenks, Munich, E. Stalil. 
1880, p. 27. 



INTERCONDYLOID FRACTURES, 



405 



more common; they show also a rather large proportion of cases of 
fibrous union. The ultimate result, so far as the restoration of function 
is concerned, varies greatly in the different cases, but is usually good 
and improves with time. 

The treatment consists in immobilization, and usually in the flexed 
position, because of a tendency to the displacement of the fragment for- 
ward and downward by the traction of the attached muscles. A common 
dressing consists of a grooved posterior rectangular splint extending 
from the shoulder to the wrist, and a short anterior one extending from 
the shoulder to the elbow. Immovable dressings are also in quite com- 
mon use, and may be used with confidence whenever displacement is 
absent or slight. Dr. Allis maintains that the posterior splint is to be 
rejected, because the turns of the bandage which is used to bind the 
forearm to the splint force the radius and the attached condyle down- 
ward and thus destroy the outward angle of the forearm, but the objec- 
tion is more easily met by the use of a moulded splint and loosely applied 
bandage than by treatment in the extended position, as he proposes. It 
will be found in practice that in some cases the flexed position and in 
others the extended position favors displacement of the radius, and the 
treatment must be varied accordingly. 

6. Intercondyloid Fractures. — In the simplest form of this variety 
the line of fracture is in the form of a T or Y, the vertical branch extend- 
ing into the joint, the other crossing the shaft more or less directly a 
short distance above. Sometimes the transverse line lies just above the 
articular surface and is quite irregular in its direction, or the fracture 
may be comminuted. These varieties are represented in the annexed 
figures. 




Fig. 220. 




Intercondyloid fracture of the humerus. 



Intercondyloid fracture of the humerus. 
Front view. (Gurlt.) 



The fracture is not a very common one, and in almost every recorded 
case appears to have been produced by direct violence, a fall or a blow 



406 



FRACTURES OF THE HUMERUS 



upon the elbow. The most frequent form of displacement is the lateral 
separation of the condyles and their ascent in front or on either side of 



Fig. 221. 



Fig. 222. 





Iiuercjndyloid fracture of the humerus. 
Hear view. (Gurlt.) 



Comminuted intercondyloid fracture of the 
humerus. (Gurlt.) 



the shaft, bringing the end of the latter near the olecranon (figs. 
223, and 224). 



Fig. 223. 



Fig. 224. 





Intercondyloid fracture of the humerus ; sepa- 
ration and ascent of the condyles ; seen from be- 
hind. 



The same, seen from the outer side. 
(Gurlt.) 



The fracture is frequently compound, and the soft parts badly lace- 
rated ; and in one case in which the end of the upper fragment had per- 
forated the skin and projected for the distance of an inch the median 
nerve had been pushed before it and was tightly stretched over its edge. 
In other cases the brachial artery has been compressed or torn. The 
cause of the displacement in the first place is usually the violence which 
produces the fracture, it is received upon the under side of the olecranon 



INTERCONDYLOID FRACTURES. 407 

and forces the latter up like a wedge between the condyles ; but the 
reproduction or the persistence of the displacement is in great part the 
result of the contraction of the triceps, biceps, and brachialis anticus. 

Marked deformity, involving the entire region of the elbow and some- 
times sufficient in itself to establish the diagnosis, is a prominent symp- 
tom, and with it are found extensive changes in the three prominences 
of the epicondyles and the olecranon, crepitation, and abnormal mobility. 
Perhaps, the most striking element in the deformity is the increase of 
the transverse diameter of the humerus at the condyles ; if this is very 
great and the olecranon has been forced up between the condyles it 
may be impossible to obtain crepitation until after the olecranon has been 
drawn down and the condyles pressed together. The direct violence, 
which, as has been said, is the common, if not the only cause of the in- 
jury, leaves its marks upon the soft parts, and the fracture is frequently 
compound. If the wound is large enough to permit exploration with the 
finger the details can usually be made out satisfactorily. 

If the fracture is simple and without such bruising of the soft parts as 
may require special treatment to prevent or diminish inflammation, the 
arm may be placed in a moulded posterior splint, or in an immovable 
dressing after reduction of the displacement. The future usefulness of 
the limb requires reduction of the displacement not only to restore the me- 
chanical conditions of the joint, but also to keep the inflammatory reaction 
within the narrowest bounds, for fibrous ankylosis is the consequence of 
the processes accompanying the latter. In my judgment early passive 
motion is not to be thought of in these cases, and the surgeon's efforts 
must be directed to maintaining reduction and keeping down inflamma- 
tion. Unfortunately it is not easy to combine the measures appropriate 
to the two indications; the rest, quiet, and pressure which are so suitable 
to the second are not entirely compatible with the frequent inspection 
that is necessary to protect against the tendency to displacement. The 
plan that seems most suitable, one that as I write has just yielded me 
a very good result, is to place the limb, flexed nearly to a right angle, 
in a gypsum posterior splint moulded to it while extension and coaptation 
are made ; then to apply a similar anterior splint over a thick layer of 
cotton, bind the two together, and make continuous extension for a 
time from the forearm close by the elbow by means of India-rubber or a 
weight. 

After three or four weeks the arm may be left loose in the posterior 
splint or even suspended in a sling, and the range of motion forcibly but 
cautiously increased once or twice a day if the attempt does not cause 
persistent pain in the joint. In this way projecting fragments that 
would otherwise limit the range may be pressed out of the way and soft 
adhesions broken or stretched. It is especially desirable that flexion to 
within a right angle should be made possible. 

In the more severe cases the surgeon may have to content himself 
with merely supporting and immobilizing the limb upon a splint or 
cushions after incomplete reduction while awaiting the subsidence of the 
swelling. 

In compound fractures the rule is well established to excise so much 
of the shaft as is necessary to make reduction and retention easy, and 



408 FRACTURES OF THE HUMERUS. 

often it is desirable to remove the condyles also, in short to do a partial 
excision. I have spoken elsewhere of the change in the treatment of 
articular fractures brought about by the introduction of the antiseptic 
method, of the expectative treatment which it justifies, and of its removal 
of the necessity for the so-called " preventive resections," those which 
were undertaken to prevent violent inflammation of the joint and reten- 
tion of the pus, but it must be remembered that the conditions at the 
elbow are not quite the same as at other joints and that it is often better 
to try there for a movable joint, even if it should be abnormally loose, 
than for ankylosis. In young people, especially, whose power to re- 
produce bone is great, an elbow after excision is, as a rule, very ser- 
viceable, and is often almost as much so as its uninjured fellow. For 
this reason and the additional one that the joint is especially difficult to 
drain and that the usefulness of the hand may be greatly diminished by 
the burrowing of pus and the formation of abscesses among the muscles 
of the forearm, a primary removal of the condyles is sometimes to be 
preferred to pure conservative or expectative treatment. It is worthy 
of note that the records show better results, so far as the mobility of the 
joint is concerned, after compound fracture with resection than after 
simple fracture. 

1 have been led to think, after the experience of some resections in 
adults, that it is best to make the excision semi-articular in such cases 
(adults), to leave the radius and ulna untouched. While it is probable 
that the mobility of the new joint will be less after such an operation 
than after a total excision, it will still be sufficiently free, and the preser- 
vation of the olecranon adds greatly to the efficiency of the triceps. 

The following case is quoted from Mr. Cheyne's statistics of Mr. 
Lister's practice 1 in illustration of this principle. 

The patient, a boy 12 years old, was admitted on account of a badly 
united fracture of the lower end of the humerus with dislocation of both 
bones of the forearm backward. The accident happened three months 
before admission ; the movements of the joint were very limited. 

" On the supposition that the case was simply one of fracture, a 
longitudinal incision was made behind the joint with the intention of 
excising it ; but the true nature of the case being revealed, it was de- 
termined to avoid interference with the bones of the forearm. A small 
slice was sawn away from the lower end of the humerus, which was 
greatly distorted and thickened by callus. The lower end of the hume- 
rus was then pared and shaped with chisel and gouge, so as to re- 
semble the natural form of the articular end of the bone, hollows being 
gouged for the reception of the olecranon and coronoid processes. The 
dislocation was then reduced ; drainage tubes inserted, and wound 
stitched. The reason for preferring this operation to complete excision 
was to avoid the lagging behind in growth of the forearm and hand, 
which is so apt to occur after that operation in young children. 

" Aseptic course. Passive motion begun on the day after the opera- 
tion. Pronation and supination were perfect from the first and always 
continued so. The limb was very strong. The movements of flexion 

i Brit. Med. Journal, Nov. 29, 1879, p. 1862, Case 18. 



INTERCONUYLOID FRACTURES. 409 

and extension were fair and were constantly improving when the patient 
was discharged [five months afterwards]." 

The following cases are quoted in illustration of the course, treatment, 
and result under varying conditions : — 

1. 1 A woman, 44 years old, fell upon the sidewalk striking upon her 
right elbow ; when seen a few minutes afterwards, the parts were already 
much swollen ; the forearm was slightly flexed . and pronated. On 
seizing the elbow firmly distinct motion could be felt above the condyles, 
also crepitus, and also the point of the upper fragment indistinctly. 
While moderate extension was made the condyles were pressed together 
and it then became apparent that they had been separated. On re- 
moving the extension, they again separated and the olecranon drew up. 
The patient was in a condition of extreme exhaustion, and the bones 
were easily placed in position. An angular splint was secured to the 
limb, and every care used to support the fragments completely but 
gently. The dressings were frequently removed and the elbow moved 
as much as it was possibly to move it. Seven months afterwards, the 
elbow was almost completely ankylosed, and the fingers and wrist were 
quite rigid. Six years later the ankylosis had nearly disappeared. 

2. H. W , 43, a large healthy man, was admitted to Bellevue 

Hospital, January 5, 1881. Shortly before, while walking, he had 
slipped and fallen, striking only upon the palm of his right hand. I 
saw him the next morning, found the right elbow much swollen, and 
recognized- an intercondyloid fracture of the humerus, probably Y- 
shaped. Each condyle could be moved separately with crepitation, the 
upper edge of each fragment could be distinctly felt on the condyloid 
ridge, and the end of the upper fragment could be felt indistinctly in the 
bend of the elbow, where pressure caused much pain. There was an 
increase in the breadth of the lower end of the humerus, estimated at 
half an inch. 

He was kept in bed with hot applications upon the elbow, and the 
limb supported upon cushions for two days, and then, the swelling 
having subsided, moulded posterior and anterior splints were applied, the 
elbow being flexed nearly to a right angle. During the hardening of 
the splints extension was made by drawing upon the forearm near the 
elbow, and lateral pressure upon the condyles by grasping them with 
one hand. Continuous extension by weight and pulley was kept up for 
several days, during which the patient remained in bed. 

31st January. The anterior splint was removed, and the arm left 
loose in the posterior one, and supported in a sling ; two or three days 
afterwards the posterior splint was removed and the patient directed to 
carry the arm in the sling. Motion at the elbow was free and painless 
through a range of about 45°, from 100° to 145°. Feb. 4th, 6th, and 
8th, I forced it gently, carrying flexion to about 80°. Pronation and 
supination were almost complete ; patient discarded the sling and used 
the arm freely in carrying small objects. Left hospital Feb. 10th. 

3. 2 A healthy man 34 years old had his right elbow crushed by the 

1 Hamilton, loc. cit., p. 280. 

2 Jonathan Hutchinson, Med. Times and Gazette, 1866, vol. i. p. 516. 



410 



FRACTURES OF THE HUMERUS. 



Fis:. 225. 



fall upon it of a heavy chest. The skin was considerably contused, and 
there was a small laceration on the inner side of the joint. We were 
not certain that this communicated with the joint, but on the next day 
the discharge of synovia-like fluid made this almost conclusive. The 
limb was got into good position, placed on an angular splint, and sur- 
rounded by bladders of ice. During the next fortnight the ice treat- 
ment was carefully and efficiently carried out. It did not, however, 

suffice to prevent a most acute attack of trau- 
matic synovitis ; there was much swelling and 
several abscesses. The suppuration was pro- 
fuse, and fearing the man's health would give 
way excision was recommended on the sixth 
week. The patient died during the prelimi- 
nary administration of chloroform. The frac- 
ture was Y-shaped, and partial union had 
taken place. Figure 225 represents the 
specimen and is a significant commentary 
upon the statement that the limb was got into 
good position. 

4. 1 A publican, aged about 50, accustomed 
to a very free mode of life, fell from some 
steps and sustained a compound fracture of 
the left elbow, the inner extremity of the 
upper fragment perforating the skin, and 
synovia escaping from the wound. The soft 
parts were much bruised. Complete excision 
of the ends of the three bones was done in 
the usual manner through a T-shaped inci- 
sion. The arm was much swollen during the first three weeks, there 
was a slight attack of erysipelas, and some delirium, "probably a com- 
plication of delirium tremens and the traumatic form." The wound 
healed and he left the hospital at the end of seven weeks. He was 
seen repeatedly afterwards, was in excellent health, and had good use 
of the arm, which he could flex and extend through a wide range. 

4. 2 George G., 60, admitted June 28, 1872, two and a half hours 
after the accident, with a compound comminuted fracture of the humerus 
caused by the passage of the wheel of a wagon over his arm. Humerus 
fractured in two places, the lower fracture communicating with the 
elbow-joint. The wound was injected with 1 to 20 carbolic lotion ; some 
loose pieces of bone removed from the lower wound. Tpyical aseptic 
course. The fracture had quite united on August 10th. The wound 
was quite superficial on August 81 and boracic dressing was applied. 
Erysipelas August 15th. Wounds healed September 20th. When 
dismissed the patient was able to flex his arm sufficiently to touch his 
opposite shoulder. 

Interrupted dressings of plaster (fig. 226) or some one of the special 
forms of splints, suspended or otherwise, so constructed as to permit the 




Displacement forward of lower 
fragments after intercondyloid 
fracture of the humerus. 



1 Hutchinson, loc. cit. 

* Cheyne, Brit. Med. Journ., 1879, vol. ii. p. 863, Case 22. 



SEPARATION OF THE LOWER EPIPHYSIS 

Fie. 226. 



411 




Interrupted plaster splint. 



dressings of the wound to be changed without the removal of the splint 
(fig. 227) should be used in the compound fractures. 




Esmarch's interrupted splint. A is to be placed outside the dressing. 

7. Separation of the Epiphysis. — The epiphysis, which includes 
both epiconclyles, grows relatively smaller as the individual advances in 
years ; it shows at first five separate centres of ossification, which are 
reduced to three some time before fusion with the shaft takes place. 
Figure 228 represents the direction of the lines at the age of fifteen 
years ; the small piece on the side is the internal epicondyle. The 
figure represents the section as seen from behind and shows the centre 
of the olecranon fossa. In consequence of the smallness of the epiphy- 
sis and its protected position its separation is a rare accident and one 
that has been rarely demonstrated by direct examination. Gurlt (loc. 
cit., vol. i. p. 82) quotes the description of a case observed in 1818 ; 
Mr. Hutchinson {Med. Times and G-az., 1866, i. p. 360) describes 
another, and Dr. Hamilton (loc. cit., p. 272) describes and figures a 
third and gives a figure of a specimen from a fourth that was presented 
to the N. Y. Surgical Society by Dr. Lange in 1880. There is also a 
specimen in the Museum of Bellevue Hospital, the bones of the forearm 
of a child with a shrunken cartilage attached which seems to be the 
lower epiphysis of the humerus. In the first and third cases amputa- 
tion was done, in the second the end of the upper fragment which pro- 
jected was excised and the patient recovered with a stiff elbow, and in 



412 FRACTURES OF THE HUMERUS. 

the fourth the epiphysis was removed through the wound and a portion 
of the shaft excised,' the patient made a good recovery and had a useful 
arm with free flexion and extension. 

Fisr. 228. 




Epiphyseal lines at the lower end of the humerus in a hoy fifteen years old. (Hutchinson.) 

Mr. Hutchison thinks he has seen "half a dozen recent examples of 
this form of injury and at least twice as many old ones in which advice 
w r as sought in consequence of the awkward deformity which often follows 
it." He describes the symptoms as like those of a dislocation back- 
ward ; conspicuous deformity, the end of the elbow projects, the tendon 
of the triceps is prominent and curved, and the forearm looks shortened. 
The diagnosis is made by observing that the relation between the ole- 
cranon and the epicondyles and the position of the head of the radius 
are not changed. The forearm is also freely movable upon the arm, 
and if the deformity is reduced crepitus can generally be felt. In the 
displacement the lower fragment is carried bodily backward with the 
bones of the forearm, which preserve their relations to it, and, according 
to Mr. Hutchinson, is rotated inward so that its inner extremity is 
prominent under the skin. 

The indications for treatment are essentially the same as in fracture 
above the condyles; to prevent bodily displacement of the fragment back- 
ward or an angular displacement that would cause the vertical axis of the 
fragment to incline forward and upward. This latter displacement is 
favored by the contraction of the flexor muscles of the forearm, and it 
is with the view of preventing it especially that Mr. Hutchinson recom- 
mends treatment by extreme flexion of the forearm upon the arm. He 
admits " that it is difficult, if not impossible, to effect accurate coaptation 
of the fragments [either in separation of the epiphysis or in fracture 



FRACTURE OF THE ARTICULAR PROCESS. 413 

above the condyles]. There is almost certain to be some overlapping, 
but still the bent position is the best one." 

8. Fracture of the Arttcular Process. — The existence of this 
variety, which appears to have been first described by Laugier, 1 who 
made the diagnosis during life of a fracture of the trochlea alone, but 
did not verify it by dissection, has been since demonstrated anatomically. 
Gurlt quotes the descriptions of two specimens, one of which shows frac- 
ture of the entire articular process, the other of the portion correspond- 
ing to the head of the radius. The first is the right humerus of an adult; 
the trochlea and capitellum have been broken off and displaced forward 
and upward, and have reunited firmly with the bone above the coronoid 
fossa. The articular surface is still covered with cartilage ; the radius 
and ulna are lacking. 

The other specimen was taken from a woman sixty-seven years old 
who, four years previously, had hurt her elbow while intoxicated. On 
examination after the swelling had subsided, a hard round prominence 
was found in front of the external condyle which did not move when the 
wrist was rotated, and pressure upon which produced crepitus. The 
diagnosis of fracture of the neck of the radius was made, but on the 
death of the patient four years afterwards the capitellum was found 
broken from the condyle and trochlea, displaced forward and upward, 
and reunited with its upper border lying in the radial depression (fovea 
anterior minor). The head of the radius lay below in the cavity left 
by its removal. The olecranon and coronoid fossae w T ere filled up with 
new deposits of bone. 

The only other case of which a clinical description is given is Lau- 
gier's, a supposed fracture of the trochlea alone, and although the diag- 
nosis is not entirely free from doubt I subjoin an abstract of the history. 
The patient was a girl, seventeen years old, who had fallen upon her 
hand. The region of the elbow was not swollen, its voluntary movements 
painful, range of passive movements complete. Crepitation was pro- 
duced within the joint by rotating the wrist, and much more clearly by 
extending the forearm completely and then bending it toward the inner 
side. When completely extended the forearm showed a slight abnormal 
inclination to the inner side which could be diminished by pressure. No 
change in the epicondyles. The diagnosis of fracture of the trochlea 
was made upon this abnormal mobility with crepitation and the integrity 
of all accessible bony points. The treatment was rest with the forearm 
half flexed and pronated. Recovery took place in a few weeks without 
loss or diminution of function. There was at no time any appearance 
of effusion within the joint. 

Laugier lays down seven propositions as characteristic of this variety 
of fracture, but as they merely restate the symptoms given above they 
do not need repetition here. 

9. Simultaneous Fracture of the Humerus and the upper end 
of the Radius and Ulna. — This variety deserves the separate classifi- 
cation which it sometimes receives, mainly because of the emphasis which 

1 Archives Generales de Med., 1853, vol. i. p. 45. 



414 FRACTURES OF THE HUMERUS. 

may thus be given to the promise held out by conservative treatment. 
The injury is a severe one, usually caused by direct violence, and usually 
compound. The fracture of the humerus may be articular or extra- 
articular ; of the other two bones the ulna is the one most frequently 
broken. The details of the fracture and of the symptoms are too diverse 
for classification. The fact to be borne in mind is that even under for- 
mer and less favorable methods of treating wounds, both life and limb 
were habitually saved by excision of the joint, and that under modern 
methods of treatment we have a right to expect to obtain a good result 
even more frequently and more easily. 

DIAGNOSIS. 

In the examination of an injured elbow the first point to which 
the surgeon's attention should be directed is the relations between 
the four principal bony prominences, the two epicondyles, the tip of the 
olecranon, and the head of the radius. If these points can be recognized 
by the finger the existence of any displacement or of a dislocation ought 
not to escape detection. The thumb and middle finger should be placed 
upon the tips of the condyles, and the index finger upon the tip of the 
olecranon. When the forearm is extended these three points are nor- 
mally in the same horizontal line, and when the forearm is flexed the 
olecranon lies below a line drawn from one epicondyle to the other. The 
head of the radius lies normally about half an inch below the external 
epicondyle, and when its shaft is not broken it can be felt to move as the 
wrist is rotated. 

Measurement of the arm from the acromion to the external condyle, 
and from the latter point to the wrist, and of the transverse diameter at 
the condyles, sometimes gives valuable information. The following is a 
brief recapitulation of the signs by which the more important' of the 
different fractures are to be recognized, and those of dislocation of the 
forearm backward are added for the sake of comparison. 

Fracture above the Condyles. — Usually the olecranon projects and 
the tendon of the triceps curves backward, and this projection is increased 
by straightening the forearm upon the arm. The normal relations of 
the olecranon and epicondyles are preserved ; there is abnormal mobility 
above the joint with crepitus. Disappearance of the deformity when 
traction is made upon the forearm, and its prompt reappearance when 
the traction is intermitted. Free and painless mobility of the joint. 

In the rarer cases of displacement of the fragment forward the re- 
semblance to a dislocation backward is lost. 

Dislocation of the Radius and Ulna Backward. — The olecranon pro- 
jects and the tendon of the triceps is curved, but the projection is dimin- 
ished by straightening the forearm upon the arm, and the tip of the 
olecranon at the same time rises above the line drawn between the two 
epicondyles. Loss of normal relations between the olecranon and the 
epicondyles. The head of the radius is displaced backward. If the 
deformity is reduced by traction upon the forearm it usually does not 
recur. Forearm slightly flexed upon the arm and almost immovable ; 
some lateral mobility. 

Fracture of the Internal Condyle. — Change in the relations of the 



FRACTURES OF THE HUMERUS — TREATMENT. 415 

epiconclyles if there is displacement. Crepitus and abnormal mobility 
recognized by grasping the condyle with the thumb and fingers and 
moving it upon the humerus, or by grasping the elbow with one hand 
and moving the forearm laterally with the other. The condyle remains 
attached to the ulna, and moves with it. Abnormal lateral mobility of 
the forearm when completely extended. 

When complicated by dislocation backward the head of the radius is 
found below and behind the external condyle, and if the finger is passed 
down along the internal condyloid ridge of the humerus it recognizes 
its abrupt termination at the line of fracture. 

Fracture of the External Condyle. — Crepitus and abnornal mobility 
recognized by manipulation of the condyle or lateral movement of the 
forearm. Change in the relations of the condyle with the olecranon 
and internal condyle, preservation of its relations with the head of the 
radius. The latter sign is of especial value in those cases in which the 
bones of the forearm are displaced outward and backward, and in w r hich 
the diagnosis is very obscure. The examination should be repeated 
after the dislocation has been reduced. 

Inter condyloid Fracture. — Marked deformity consisting in increase 
of the breadth of the humerus at the condyles, often shortening of the 
arm ; marked change in the relations of the bony prominences ; inde- 
pendent mobility of each condyle upon the shaft and upon each other ; 
crepitation, which, however, may not be obtained until after the forearm 
has been drawn forcibly downward and the condyles pressed together. 
Comminution may, perhaps, be recognized by the freer crepitation and 
abnormal mobility. 

TREATMENT. 

The methods of treatment suitable to the different varieties have 
been mentioned in connection with each. The violence of the reaction 
may call at first for measures to reduce the inflammation, and some 
surgeons prefer to postpone the application of splints until the swell- 
ing has subsided, placing the limb meanwhile upon pillows. Others 
apply a w T ell-paddecl temporary splint to prevent motion of the fragments 
by muscular twitching or accidental change of posture. Hot applica- 
tions, or lead and opium, or evaporating lotions are applied to the elbow, 
and leeches are sometimes used. In a few cases 1 have been much 
pleased with the benefit derived from a rubber bandage covering the 
hand, forearm, and half the arm. Used immediately after the injury 
it has prevented pain and swelling, and at a later period it has rapidly 
reduced the latter. It should be applied rather loosely at first, watched 
closely, and tightened or loosened as circumstances may indicate. 

Some surgeons first apply a roller bandage from the hand to the axilla 
to prevent spasm and limit the swelling, but the practice is dangerous. 
There is, perhaps, no risk in placing the bandage upon the hand and 
forearm, but it should not be carried above the fracture. 

The best moulded posterior splint, when it is designed to hold the 
fragments closely, is one of gypsum, and an elegant finish can be given 
to it by placing a thin layer of sheet lint between it and the skin. If 
the tendency to displacement is slight, if the parts have been bruised 
and swelling is anticipated, a layer of cotton may first be placed upon 



416 FRACTURES OF THE HUMERUS. 

the limb, then the posterior splint fitted, and a roller bandage placed 
snugly over all ; a similar anterior splint is sometimes needed in addition. 

A convenient splint that allows easy inspection is the one recom- 
mended by Dr. Allis, and described in the section on fractures of the 
internal condyle, or a similar one made with dextrine or silicate of soda; 
that is, a layer of cotton about the limb from hand to shoulder, bound 
down and covered in with a roller bandage stiffened with the white of 
egg. Retention of the fragments is aided by longitudinal strips of ad- 
hesive plaster upon the skin. This is sufficiently firm to keep the limb 
in the position selected, and if split longitudinally it can be easily sprung 
off without affecting its shape. It does not control the fragments directly, 
and cannot therefore be depended upon to prevent displacement if there 
is any active agency present to cause it ; it acts only by keeping the 
limb in the selected position, and at the same time allows inspection. 

The position in which the elbow is midway between a right angle and 
complete extension, or even a little nearer the latter, is to be recom- 
mended in most cases; the exceptions are fractures of the epicondyles, 
of the internal condyle with dislocation backward, and, perhaps, also 
of the external condyle. Berthomier 1 found by experiment upon the 
cadaver that the position of extension was more favorable than flexion 
to accurate coaptation of the fragments in all fractures except those of 
the epicondyles and external condyle, and recommended it as the habit- 
ual position for treatment. The question cannot be decided by cadaveric 
treatment, because this leaves out the highly important element of mus- 
cular contraction, but the practice is certainly gaining clinical support. 

An anterior splint (fig. 229) is employed by some in preference to a 
posterior one. It is usually made of wood with a fixed angle or a hinge 

Fig. 229. 



Anterior splint. 

that permits the angle to be changed, and is fastened to the arm with a 
roller bandage, a layer of cotton or a compress being interposed between 
it and the skin. 

I have already expressed my opinion concerning the value of passive 
motion. I believe that employed with vigor, at any time during the 
first three weeks, it is more likely to do harm than good. I do not 
believe it is proper during this period to move the limb in such a manner 
as to cause pain. I have seen an elbow stiffen rapidly, and a range of 
motion of more than 90° lost entirely within a week under this practice. 
But there is no objection to changing the position in which the limb is 
kept, even daily, after the first week or two, and that can be conven- 

1 Fractures du Conde cliez les Enfants, These de Paris, 1875. 



FRACTURES OF THE HUMERUS. 41? 

iently done by means of the anterior hinged splint. At each dressing 
the angle is changed a few degrees. If the surgeon wishes to make 
passive motion he should support the elbow by grasping it firmly with 
one hand, while he carefully extends and flexes the forearm with the 
other. 

Even under the most favorable circumstances the joint will be more or 
less stiff when the splints are first removed, and the tissues about it will 
be more or less swollen and indurated. The latter condition is readily 
corrected by rubbing and by the temporary use of a rubber bandage ; 
and the first will ordinarily disappear rapidly as the arm is used. The 
exceptions are the cases in which the form of the joint has been mate- 
rially changed, in which a mechanical obstacle to flexion or extension is 
presented by a displaced fragment or by an overgrowth of callus, and 
those in which the severity or the duration of the inflammation has re- 
sulted in a permanent retraction and thickening of the capsule and 
periarticular tissues. 

Constant and rather forcible use of the arm will increase the range of 
motion rapidly, especially in the direction of flexion, an additional rea- 
son for dressing the limb in the extended position. I have often heard 
a friend, a skilful and experienced surgeon, speak with much satisfac- 
tion of the rapidity with which in one case an elbow, stiffened after 
fracture, regained its mobility under his observation. The patient was 
a young lad, and the stiffness had resisted forcible attempts at passive 
motion made almost daily for some time. My friend advised the parents 
to give the boy a boat and let him spend his time upon the water. 
Nothing was clone to the elbow, but within two months it had recovered 
its full range of motion. 



27 



418 FRACTURES OF THE BONES OF THE FOREARM. 



CHAPTER XXII. 

FRACTURES OF THE BONES OF THE FOREARM. 

A. In the Vicinity of the Elbow-Joint. 

1. Fracture of the Olecranon. — The frequency of fractures of the 
olecranon has been very differently estimated by different writers, Mal- 
gaigne placing it among the rarest, only 9 cases in a total of more than 
2300 fractures treated during eleven years at the Hotel Dieu, while in 
the tables given in Chapters I. and IX. it rises to 3 per cent. The per- 
sonal experience of individual surgeons seems to differ even more widely ; 
Hoin, according to Malgaigne, saw only one case during thirty years of 
hospital service at Dijon, Camper two, and Malgaigne six ; while, on the 
other hand, Hamilton says his records contain accounts of seventeen 
cases. I have seen four in three years, and five cases were admitted 
during a single year into one division of Bellevue Hospital. 

Fi?. 230. 




The olecranon, divided vertically. 



The most common cause is a fall or blow upon the elbow. Muscular 
effort, contraction of the triceps, appears to be an occasional cause, and 
it has been recently alleged that a blow upon the ulna near the elbow 
can break or crack the olecranon from the articular surface outwards. 
The position of the fracture varies apparently with the cause ; it may 
lie close to and parallel with the upper end of the process, or at any in- 
termediate point above the base of the coronoid process crossing the bone 
transversely or obliquely, or along a V-shaped line corresponding some- 
what to the borders of the triangular subcutaneous surface of the 
olecranon. In rare cases it is comminuted, and sometimes is compound. 

The commonest cause by far, in 36 out of 45 cases collected by 
one writer, is a fall upon the elbow. The .mechanism, however, is 
not simply that of fracture by direct violence, the bone is not broken by 



IN THE VICINITY OF THE ELBOW-JOINT. 419 

a force acting directly upon the end of the apophysis, but the contrac- 
tion of the triceps must play an important part in it. Among the reasons 
for this belief are the usual absence of the signs of direct violence upon 
the surface of the region sufficient to have caused the fracture, and the 
impossibility of producing similar fractures upon the cadaver by this 
means. When the fracture is produced experimentally by direct vio- 
lence, by a blow with a blunt object, the bone is not broken cleanly and 
transversely at its narrowest part, as is the case in most fractures ob- 
served clinically, but it is crushed and split into several pieces. The 
explanation that seems most plausible is that a sudden change is effected 
in the position of the forearm by the fall when the muscles are all tense. 
The man falls with his elbow partly bent, and all his muscles rigid with 
the effort to save himself; his outstretched hand, or the back of his 
forearm encounters some solid object, and the flexion of the limb is sud- 
denly and violently increased, while the olecranon is held immovable by 
the triceps. The consequence is that the ulna is bent about the elbow, 
and breaks at the weakest part of the olecranon if the violence is re- 
ceived near the elbow, or, perhaps, at some part of its much thinner 
shaft if the violence is received upon the hand ; in short, the bone is 
broken across the elbow as a stick is broken across the knee. 

In a few cases the olecranon has been broken in an attempt to reduce 
an old dislocation ; in others it has been broken at the same time that 
dislocation took place backward or forward. I saw it broken once in 
an attempt to flex a stiff elbow; and Malgaigne (loc. cit., vol. ii. p. 575) 
quotes a very singular case of fracture, in part at least, by muscular 
action: A man twenty-one years old, who had shown a marked dispo- 
sition to fracture in youth, was carrying a heavy pitcher of water in his 
hand. He felt pain in the elbow, which increased gradually and then 
suddenly became sharp, with a cracking sound. There was found a 
transverse fracture of the olecranon with a complete dislocation backward 
that could not be reduced. 

Fracture by muscular action is rare. Malgaigne examined critically 
five cases reported as such, and rejected two of them as at least doubtful. 
The three which he accepted as actual examples of fracture by muscular 
action were reported by Capioment, Richerand, and Blanclin. In the 
first the patient was left alone to hold a capstan, and while making a 
vigorous effort to keep it from turning back, felt something crack in his 
elbow, and at once lost power in the arm. The olecranon was found to 
be broken. In the second the fracture was caused by an effort to throw 
a ball, and in the third bv extending the arm in diving. To these Mai- 
gaigne adds a fourth, observed by himself, but it is one which perhaps 
should be explained rather by the mechanism described in the last para- 
graph but one : a man thirty years old, playing with a comrade, had his 
forearm suddenly and forcibly flexed upon his arm while resisting ; he 
felt a sharp pricking pain, but returned to his work ; flexion became more 
and more painful ; he consulted a surgeon, and the apex of the olecranon 
was found to have been torn off. Monte o-gia tells of a woman who broke 
her olecranon by striking her maid. 

In fractures due solely to muscular action the fragment torn off is 
small, little more than the cortical layer of the summit of the process to 



420 FRACTURES OF THE BONES OF THE FOREARM. 

which the triceps is principally attached ; in other cases the line of frac- 
ture lies usually at the narrowest part of the process, directly under the 
centre of the sigmoid fossa, that which is called by some the centre, by 
others the base of the olecranon. 

Another variety of fracture, partial or complete, and produced from 
within outwards, has been spoken of by different writers as theoretically 
possible, but has only recently been observed and described clinically. 
Pingaud 1 produced it experimentally in the effort to dislocate the ulna 
backward by over- extension (extension beyond the straight line) of the 
forearm. The end of the olecranon is pressed against the humerus, the 
lateral ligaments resist the movement, and the prolongation of the effort- 
results in fracture of the olecranon or, much more commonly, of the 
thinner and weaker shaft of the ulna. Quintin 2 reports three cases of 
incomplete fracture of the olecranon ; the surface articulating with the 
humerus was broken, the dorsal portion was unbroken ; in all the swell- 
ing was moderate, the pain severe, flexion and extension complete but 
slow. In the first case, seen a week after the accident, a small promi- 
nence could be felt on the side of the olecranon, and behind it was a 
notch; the upper end could be sprung back a little. In the second case 
a short shallow groove could be felt on the outer side of the olecranon, 
at its base ; and in the third the olecranon could also be sprung. Quin- 
tin thinks this fracture is frequently overlooked and treated as a simple 
contusion. The symptoms in the three cases described will, perhaps, 
hardly be considered entirely demonstrative in the absence of corrobo- 
rative testimony, of direct examination of a recent fracture ; and, indeed, 
it is only by admitting that the injury is a common one and has hereto- 
fore always been overlooked, that its occurrence three times during a 
short period in the experience of one observer can seem probable. Cor- 
roborative testimony is said to be furnished by experiments upon the 
cadaver made by Madelung and Lesser, who found that when the blow 
fell directly upon the olecranon, the forearm being partly flexed, the 
result was a fracture of the olecranon from without inward (from the 
dorsum towards the articular surface), the end of the process being bent 
into the olecranon fossa ; while if the violence was distributed more 
widely upon the upper third of the forearm, the result was either frac- 
ture of a condyle, T-shaped fracture of the humerus, or fracture of the 
olecranon in the opposite manner, from within outward, its apex being 
bent away from the fossa instead of toward it. I fail to understand the 
mechanism as it is described, and confine myself, therefore, to this brief 
restatement of the author's views. 

Symptoms. — The symptoms of the fracture are pain, swelling, dis- 
placement, and mobility of the upper fragment, sometimes crepitation, 
and loss of power, especially of active extension. Some of these symp- 
toms require more detailed notice. 

As the result, apparently, of theoretical considerations, and of what 
has been observed in exceptional cases, the tendency to displacement 
upward of the fragment by the contraction of the triceps has been some- 

1 Diet. Encyclopedique, art. Coude, pp. 517 and 631. 

2 Beitrag zur Lehre von den Briichen des Olekranon, Bonn, 1881, Abstract in 
Centralblatt fur Chirurgie, 1881, p. 763. 



IN THE VICINITY OF THE ELBO-W- JOINT . 421 

what overstated. This action of the muscle is greatly restricted by the 
lateral aponeurotic attachments and ligaments, and by the extension of 
the insertion of the triceps along the lateral and posterior aspects of the 
olecranon, all of which must be ruptured before the fragments can be 
widely separated and the upper one drawn high up. In a discussion in 
the Society de Chirurgie 1 which followed the presentation by Bardinet 
of a paper upon this subject, Robert, Richet, and Gosselin testified to 
the usual absence of separation in their experience, and similar testimony 
has been since furnished in abundance. 

If the thick periosteum and tendinous attachments on the sides and 
back of the olecranon are torn, nothing remains to hold the fragments 
together, and separation may be effected either by the contraction of the 
triceps, drawing the upper fragment away from the shaft of the bone, or 
by the flexion of the forearm, drawing the bone away from the fragment. 
In either case coaptation is effected by extending, straightening, the fore- 
arm upon the arm, because the triceps cannot draw the fragment above 
the position which it takes in complete extension unless the ligaments 
which bind it to the humerus are torn, and this is a complication which 
apparently happens very rarely. Some authors speak of a separation 
of one or two finger-breadths and even of one or two inches, but do not 
indicate the position of the joint at the time the measurement was taken. 
In a case dissected and pictured by Sir Astley Cooper 2 he says : " the 
olecranon is separated two inches from the ulna ; the capsular ligament 
of the elbow-joint is torn through on each side of the olecranon ; and the 
separated portion is united by a ligamentous band which is stretched from 
one broken extremity of the bone to the other." The accompanying 
drawing represents the elbow flexed at a right angle and the olecranon 
just behind its own fossa, so that it seems probable that the separation 
would be much less if the forearm were extended. Such a degree of 
separation is entirely exceptional, and even in cases in which reunion of 
the fragments has failed, the upper one has not risen above the olecranon 
fossa. It may also happen that a separation which is slight at first may 
be afterwards increased by forcible flexion of the arm or by a voluntary 
effort to extend it. 

Another displacement, one that is important because of the danger 
that the skin may be broken by the pressure which it leads to, is an 
angular one observed in a few cases when the line of fracture has been 
near the base of the coronoid process, and especially when its direction 
has been obliquely downward and backward and the upper fragment has 
ended in a sharp lower edge or point. In the discussion in the Societe 
de Chirurgie above referred to, Robert mentioned a case of this kind in 
which perforation occurred after about two weeks. Robert, who was at 
the time Dupuytren's interne at the Hotel Dieu, admitted the patient, 
who had been severely injured in other ways, recognized the fracture of 
the olecranon, and dressed the limb in the extended position. A few 
days afterwards Dupuytren removed the dressing, found no displace- 
ment, and, apparently doubting the diagnosis, left the limb without 
splints. No attention was paid to it until ten days afterwards when 

1 Bulletins de la Soc. de Chirurgie, vol. vi., 1856. p. 152. 

2 Dislocations and Fractures, Am. ed., 1851, p. 413, Case 238. 



422 FRACTURES OF THE BONES OF THE FOREARM. 

perforation was found to have occurred. Richet spoke of a similar case in 
his own practice, but the report of his remarks leaves it uncertain whether 
the perforation was due to pressure or to the formation of a large abscess. 
Gosselin had a case in which the displacement was irreducible. 

Mobility of the fragment is recognized by grasping it between the 
thumb and finger and moving it laterally, or by flexing the forearm 
gently w T hile the finger is pressed against the groove or crack left by 
the separation when it is slight. If the fragments are brought together 
by extending the forearm or drawing the upper fragment down, crepi- 
tation can be felt. 

If the swelling is sufficient to prevent recognition of these objective 
signs, the fracture may be suspected from the history of the case and 
the loss or marked diminution of the power of active extension. 

In a case of compound fracture observed by Rey, 1 the surface wound 
being a small one over the posterior aspect of the olecranon, air entered 
the joint with a whistling sound when the elbow was flexed and came 
out in bubbles when it was extended. There was no displacement of 
the fragment, and the patient made a good recovery with bony union 
and slight limitation of motion. 

Repair. — It is very important, with reference both to treatment and 
prognosis, that the character and extent of the displacement should be 
known. As a rule, union takes place, but it is fibrous, not bony ; and 
the restoration of function depends in a measure upon the length of the 
fibrous band. I say " in a measure," for experience has shown in not a 
few cases that there may be excellent control over the limb even with a 
long fibrous band between the two fragments. The disability some- 
times observed under the opposing conditions, limitation of motion when 
the band is short, is due to adhesions between the fragment and the 
humerus, or to change in the flexibility and length of the capsular bands. 
The process of repair involves two dangers : defective union or failure 
of union between the fragments, and the formation of intra-articular 
bands or changes in the articular and peri-articular tissues. 

Instances of bony union do exist. Malgaigne figures and describes 
one in his Atlas (PL XXIV., fig. 2), which, however, differs notably 
from the ordinary fracture, the line having run so obliquely as to bring 
away with the olecranon a lateral half of the coronoid process. Many 
instances of union with very slight separation, if any, and apparently 
bony, have been reported, but in only a few has the character of the 
union been established by autopsy. Gurll 2 describes and pictures two : 

one, a fracture half an inch from 
Fig. 231. the apex of the process, united with 

slight displacement of the fragment 
upward and only a small amount of 
callus on the outer side ; the line of 
fracture is partly visible upon the 
surface of section, and complete ex- 
tension of the joint is prevented by 

Fracture of olecranon; bony union. (Gurlt.) »I1 OVergl'OWth of bone at the apex. 

1 Union Medicale, 1873, vol. xv. p. 208. 

2 Loc. cit., vol. i. p. 41, fig. 9, and p. 310, fig. 121. 




IN THE VICINITY OF THE ELBOW-JOINT. 423 

The other is an oblique fracture (fig. 231), and has united so completely 
that the only sign of it is " a shallow groove on the under surface of 
the olecranon running obliquely backward from the radial to the ulnar 
side. The articular cartilage is lacking in part, and the callus conse- 
quently visible." 

Mr. Fletcher, 1 of Liverpool, reported a case of bony union of both 
olecranons, verified by examination after death. The patient, a boy 
16 years old, was admitted to the hospital May 19, 1850, having frac- 
tured both olecranons a short time before by falling over some timber. 
There was separation to the extent of a finger's breadth. Tne fractures 
were treated with the arm in the extended position "' for the usual time," 
the stiffness was then gradually overcome by passive motion, and the 
patient was discharged July 21. He was re-admitted in the following 
January, having full use of both arms, and died of phthisis March 9th. 

Full osseous union was found. The signs of fracture were an irregu- 
lar furrow on the surface of each sigmoid cavity two lines wide, along 
which the articular cartilage was entirely wanting. On the right ole- 
cranon this furrow was three-eighths and on the left five-eighths of an 
inch from the humeral end. Posteriorly there was no furrow or pro- 
jection, but a slight deviation from the normal line beginning about an 
inch from the humeral extremity. On section, the cancellated structure 
above the line of fracture " was slightly condensed, but all remains of 
the callus seem to have been removed." 

It is to be noticed that in three of these the fracture was oblique, and 
this corresponds with the result of experiments made by Sir Astley 
Cooper. He found that transverse fractures of the olecranon in dogs 
and rabbits united by fibrous tissues, but that union after very oblique 
fracture was bony, and he explained the difference in the result by the 
lack of contact between the fragments in the former case. 

The length of the fibrous band varies within very w T ide limits. Figure 
232 taken from Malgaigne represents a comparatively short band and 

Fig. 232. 




Fracture of the olecranon ; fibrous union. (Malgaigne.) 

one that presents another peculiarity in that it consists of two lateral 
bands with a central interval or gap. This is by far the most common 
mode of reunion, and although several cases have been reported in which 
the patient appeared to have regained full use of the arm, notwithstand- 

1 Med. Times and Gazette, 1851, vol. ii. p. ]73. 



424 FRACTURES OF THE BONES OF THE FOREARM. 

ing fibrous union with separation to the extent of half an inch or more, 
yet actual deficiency in the power of active extension of the forearm is 
to be regarded as the natural and almost inevitable result of fibrous 
union, and its degree will vary directly with the length of the band. 
The disability may be unnoticed by others, and its consequences may 
be avoided or diminished by care in the use of the arm, by avoidance of 
positions and movements which require the especial action of the triceps, 
but it exists and can be readily demonstrated. Malgaigne describes a 
case in which the fragment apparently had not reunited with the shaft, 
and yet the patient could use the limb actively, and even handle a sword 
or foil. On examination it was found, however, that the vigor and 
strength of the arm depended largely upon its position, being greatest 
when the hand was supinated and the arm dependent, and disappearing 
almost entirely when the arm was raised above the horizontal line. 

Failure of union, as in the case just mentioned, is not very uncommon ; 
the upper fragment may remain freely movable, or it may become ad- 
herent to the humerus. An example of the latter condition came under 
my observation in Bellevue Hospital. The patient, John A., 56 years 
old, was admitted in August, 1880, for some slight affection, and while 
examining him I noticed the defect of the right elbow. He said that when 
about twenty years old he fell from a truck, striking upon the elbow. 

Fie. 233. 




Ununited fracture of the olecranon. A, the upper fragment. B, the external condyle. 
(From a photograph.) 

The limb was treated in a rectangular splint. The upper fragment, as 
shown in figures 233 and 234 taken from photographs, is slightly drawn 
up and somewhat tilted, and is firmly adherent to the humerus. The 
forearm can be completely flexed and can be extended to 135°, the force 
of extension being very feeble. 

A similar case was presented to the Pathological Society, of London, by 
Wm. Hutchinson. 1 The patient had received a transverse fracture of the 
olecranon ten years previously which was treated with the elbow flexed. 

1 Lancet, 1881, vol. i. p. 56. 



IN THE VICINITY OF THE ELBOW-JOINT. 



425 




u The fragment is fixed almost immovably to Fi o» 23 4. 

the humerus with a wide gap between it and 
the ulna, in which there appears to be not 
any uniting medium. He has power in his 
triceps and can partly extend the elbow ; he 
has also partial paralysis of the ulnar nerve, 
with contraction of the ring and little fingers, 
numbness, and wasting of the muscles be- 
tween the thumb and forefinger." 

In the majority of cases union takes place 
with but little separation and with full resto- 
ration of function, so far at least as power is 
concerned, although extension is often incom- 
plete. 

A still more unfortunate result, ankylosis 
of the joint, has followed in a small number of 
cases. Malgaigne quotes from Camper and 
Trioen, an anatomical specimen of bony 
fusion, and although it is not specifically 
asserted that the union was between the ulna 
and the humerus, this seems probable from 
the context. Thierry, according to Pingaud, 
reported two cases of articular rigidity that 
had lasted, the one for six months, the other 
for a year, in spite of the most persistent 
efforts to overcome it. 

The course of the fracture is ordinarily very simple and uncomplicated ; 
the swelling subsides promptly and union takes place in from three to 
four weeks. 

Treatment. — Discussion concerning the proper treatment of fracture 
of the olecranon has turned mainly upon the position to be given to the 
limb, some favoring the extended position in order to secure closer union 
of the ligaments, others recommending flexion either because they did 
not fear separation of the fragments and sought the position that could 
be kept with the least discomfort, or because they feared ankylosis and 
wished to have the limb in the most favorable position if it should occur. 
It is evident from the facts that have been already stated that neither 
the first nor the third reason is sufficient to establish a rule of practice 
to be followed in all cases. The probability of the occurrence of anky- 
losis after simple fracture is very small, so small that it ought not to be 
weighed against that of non-union when the fragments are separated 
rather widely. On the other hand, the separation at first is so slight in 
many cases and the extended position so unnecessary to overcome it that 
if partial flexion is more comfortable to the patient, if it makes the 
restraint less irksome, it should not be denied him. Furthermore, there 
appears to be clanger of two displacements in complete extension : if the 
fracture is at or near the base of the process the ulna can be readily 
dislocated forward ; and secondly, effusion into the joint or swelling of 
the capsule may prevent the tip of the olecranon from sinking into the 
olecranon fossa to the usual depth, and under such circumstances com- 



The same : the arm extended. 



426 FRACTURES OF THE BONES OF THE FOREARM. 

plete extension of the forearm would cause a tilting, an angular displace- 
ment of this fragment. This latter point has been made by several 
■writers upon theoretical grounds alone, and although it seems reason- 
able and plausible, no confirmatory observation has been made, so far as 
I know. 

The aim of treatment should be to secure bony union if possible, and, 
failing that, close fibrous union, and this consideration will regulate the 
position to be given to the arm. If there is wide separation which in- 
creases as the elbow is flexed, if the fragments cannot be brought well 
together except by extending the forearm, that position must be taken 
and kept until consolidation is well advanced. If, on the other hand, 
the separation is slight and the upper fragment follows the movements 
of the lower, if they can be easily brought together and kept so by 
moderate traction upon the upper one, the patient maybe safely allowed 
the comfort of the partly flexed position. 

Apparently it is not often necessary to take especial measures to draw 
the upper fragment down to the lower one, and even when there is con- 
siderable separation between them in the flexed position it is usually suffi- 
cient simply to extend the elbow. Some methods of treatment, however, 
have been designed with the especial intention of drawing the fragment 
down, and it has been sought to accomplish this by figure-of-8 bandages 
passing above and below the fragment and crossing in front of the elbow, 
or by circular bands about the arm drawn together by longitudinal ones. 
In others, strips of adhesive plaster have been applied to the skin above 
the olecranon, drawn down snugly, and fastened to the skin of the fore- 
arm or to the splints ; sometimes the plaster is cut in the form of a U, 
the olecranon lying in the angle and the two sides passing along the 
forearm. 

Metal hooks similar to those used in fracture of the patella have also 
been used here successfully, although not frequently. I do not know 
when or by whom they were first employed, but Busch recommended 
them in 1864, and Pmgaud 1 speaks of the use of a similar method " a 
very long time ago" by Prof. Rigaud, of Strasburg. It is sufficient 
that the hook should have but a single point at the upper end, and that 
the other end should be made fast to a gypsum bandage covering the 
arm and forearm, and provided with a large fenestra behind the elbow. 
The best splint is an anterior one made fast to the limb by a roller 
bandage or a fenestrated gypsum bandage. It is not worth while, I 
think, to try to force the upper fragment down by turns of a roller 
bandage, because this can be done much more effectively when necessary 
by adhesive plaster or hooks. In short, the treatment to be recom- 
mended is as follows : If the separation is slight and is not increased by 
the flexed position it is only necessary to immobilize the limb with the 
forearm slightly flexed, about midway between complete extension and 
flexion at a right angle, and for this purpose an anterior splint of wood 
or of plaster of Paris is sufficient and convenient. If the fragment 
shows any tendency to be drawn up it should be secured with adhesive 
piaster. If, on the other hand, there is notable separation, and if the 

1 Diet. Encyclopedique, art. Coude, p. 639 (1878). 



IN THE VICINITY OF THE ELBOW-JOINT. 427 

separation is increased by flexion of the forearm, the extension should be 
complete enough to bring the fragments together, and it should be aided 
by adhesive plaster or hooks. The fenestrated gypsum bandage seems 
to be the one best fitted for this purpose, and the fenestra should be large 
enough and so placed as to permit inspection of the seat of fracture. If 
Malgaigne's hooks are used in connection with it one hook or pair of 
hooks should be forced through the tendon of the triceps down to the 
bone, and the other pair fixed to the gypsum bandage below the fenestra. 
In one of three cases recorded by Quintin, 1 the hooks remained in place 
four weeks without causing any inflammatory symptoms. 

If the patient is rheumatic, or if the reaction has been severe and 
prolonged, and ankylosis is feared, it is well to change the degree of 
flexion slightly from time to time after the pain and inflammation have 
disappeared ; and if the tendency to separation is slight this change of 
position may be began quite early. It must be done very gently and 
cautiously, and the upper fragment must be supported by the finger in 
order that the adhesions may not be ruptured. In a case reported by 
Pingaud, 2 the callus was broken by this attempt at passive motion ; and 
as the surgeon did not dare to immobilize the joint again for three or 
four weeks he applied a plaster bandage to the forearm, and used it as 
the support for a pair of Malgaigne's hooks by which he was enabled to 
keep the fragment perfectly in place, and at the same time to move the 
elbow as much as he wished. 

Lauenstein 3 has used in one case a method of preliminary treatment 
recommended by Volkmann in fracture of the patella ; aspiration of the 
joint to remove the blood and synovia. There was separation to the 
extent of half an inch and the joint w T as distended ; he removed fifty 
cubic centimetres (about 1J ounces), dressed the limb in the extended 
position upon an anterior splint, and drew down the fragment by means 
of longitudinal strips of adhesive plaster renewed about once a week. 
Recovery followed without displacement and with full use of the joint. 

In a few cases of fibrous union with much separation and consequent 
disability operative measures, according to some of the various plans 
mentioned in Chapter IX., have been undertaken to obtain closer union ; 
and since the introduction of the antiseptic method some surgeons have 
obtained good results by excising the fibrous band and wiring the frag- 
ments together, as in the following case. 4 The fracture had united by a 
fibrous band with loss of the power of active extension. Three months 
after the injury, Mr. Rose cut down upon the fracture and wired the 
fragments together, passing the wires in such a way that they did not 
enter the joint. He used antiseptic precautions and horse-hair drains, 
began passive motion on the tenth day, and removed the wires after the 
end of the fifth week. The result was bony union of the fracture with 
good use of the joint. 

2. Fracture of the Coronoid Process. — This fracture, the fre- 
quency of which has been much disputed, is unquestionably very rare 

1 Centralblatt fur Chirurgie, 1881, p. 764. 2 Gazette Hebdomadaire, May 21, 1875. 

3 Centralblatt fur Chirurgie, 1881, p. 172. 4 Lancet, 1880, vol. i. p. 835. 



428 FRACTURES OF THE BONES OF THE FOREARM. 

except as a complication of dislocation of the ulna backward. Dr. 
Hamilton devotes several pages to a discussion of the alleged cases of 
this injury and rejects most of them as unproven, saying in conclusion 
" we are left with no evidence that the coronoid process was ever 
broken by the action of a muscle, and with only one example in which it 
is probable that a fracture occurred as a consequence of a dislocation of 
the radius and ulna backward." To reach this conclusion Dr. Hamilton 
has had to reject all alleged cases supported only by clinical evidence 
and three of the four specimens of which he had knowledge. These 
four are the cases of Sir Astley Cooper, Samuel Cooper, Velpeau, and 
Dr. Gibson of Richmond, and he accepts only the first. He rejects the 
second because " it seems to have been a general crushing of all the 
bones concerned in the formation of the elbow-joint," the third, because 
he lacks a circumstantial knowledge of its condition, and the fourth, be- 
cause " he finds it easier to believe that Dr. Gibson is deceived by cer- 
tain appearances than that it [the fracture] should have united by bone 
again, and so perfectly as not to leave any line of separation or degree 
of displacement." 

These arguments for rejection do not seem sufficient ; and in view 
of the possible importance and frequency of the lesion I think it desira- 
ble to present the reasons for claiming that the occurrence of fracture 
of the coronoid process has been demonstrated by direct anatomical 
evidence, that the possibility of repair without notable displacement has 
been similarly proven, and that, as its occurrence as a complication of 
dislocation of the elbow backward has been demonstrated by direct ex- 
amination and by experiment, the diagnosis in the numerous clinical 
cases in which its existence has been asserted must be accepted as in all 
probability correct. 

The anatomical proofs are twelve in number. 

1. The specimen mentioned by Sir Astley Cooper (loc. cit., p. 411). 
It was found in the dissecting room, was without history, and is preserved 
in the museum of St. Thomas's Hospital. " The coronoid process which 
had been broken off within the joint, had united by a ligament only, so 
as to move readily upon the ulna, and thus alter the sigmoid cavity of 
the ulna so much as to allow in extension that bone to glide backwards 
upon the condyles of the humerus." The external condyle was also 
broken off" and united by ligament. 

2. A specimen contained in the University College Museum and 
described by Samuel Cooper. 1 There is fracture of the ulna " at the 
elbow," fracture of the coronoid process, and dislocation of the head of 
the radius. 

3. A specimen in the possession of Dr. Chas. Gibson, of Richmond, 
Va. 2 " The process was broken transversely near its extremity, and has 
united again quite closely and without any displacement, and without 
ensheathing callus." 

4 and 5. Two cases observed by Velpeau. 3 He says in a note at- 
tached to a paper by Debruyn upon dislocations of the elbow, " when 

1 Quoted by Hamilton, loc. cit., p. 342. 2 Hamilton, p. 343. 

3 Amiales de la Chirurgie, vol. ix., 1843, p. 98. 



IN THE VICINITY OF THE ELBOW-JOINT. 429 

the forearm is dislocated backward it happens, more frequently than 
seems to be thought, that the coronoid process is broken. I have seen 
this fracture, which was first mentioned by Berard, in two patients whose 
elbows I was able to dissect after their death." The details of one of 
these cases are given in the same publication, vol. i. p. 299. The patient 
w T as a man 50 years old whose elbow was dislocated in a fall. Six weeks 
afterwards he consulted Yelpeau who recognized a dislocation but was 
unable to reduce it. The patient died of erysipelas and the autopsy 
showed fracture of the coronoid process, and a transverse fracture of the 
anterior third of the head of the radius. 

6. Berard 1 in 1834 examined the body of a man who had been killed 
by a fall from the second floor of a building. The elbow showed the 
signs of a dislocation backward which could be reduced without much 
difficulty and reproduced with slight crepitation by moderate pressure. 
The dissection snowed a fracture of the coronoid process, and fracture of 
the head of the radius separating a fragment composed of the anterior 
third of the articular surface and the adjoining half inch of the anterior 
aspect of the neck. 

7. A specimen (fig. 235) preserved in the museum at Braunschweig, 
and described and pictured by Gurlt (loc. cit., vol. i. p. 41, fig. 10). 
Fracture of the extremity of the coronoid process of the right ulna ; the 
line of fracture is visible about two and a half lines from the point on 
the articular surface. On the ulnar border of the articular surface of 
the olecranon is a small fragment which has been broken off and has 
reunited. 

Fig. 235. Fig. 236. 



,-) 







Fracture of coronoid process of the right ulna. Fracture of the coronoid process and the 

United with exuberant callus on the anterior surface, head of the radius. (Bryant.) 

line of fracture still visible on the articular surface. 
a, a small fragment biokeu from the articular border 
of the olecranon and reunited. (Gurlt. ) 

8. A specimen in the museum of Guy's Hospital (fig. 236) described 
and pictured by Bryant. 2 The patient was a woman TO years old, and 
the injury was caused by a fall upon the elbow. The anterior third of 
the head of the radius was also broken off. 

9 and 10. 3 Specimens preserved in St. George's Hospital and taken 
from the body of a man who was killed by falling from the roof of the 
hospital. Both forearms were dislocated backward, both coronoid pro- 
cesses broken, and the head of each radius split longitudinally. 

1 Diet, de Medecine en 30 volumes, art. Coude, p. 228. 

2 Surgery, 3d Am. ed., p. 837. 

3 Holmes's System of Surg., Am. ed., vol. i. pp. 859 aud 860. 



430 FRACTURES OF THE BONES OF THE FOREARM. 

11. Allandale 1 describes in a clinical lecture an excision of the elbow 
for an old unreduced dislocation of the forearm backward in a girl 18 
years old. After having removed the olecranon he says "we now find 
that there has been a fracture of the coronoid process at the time of the 
accident which has been followed by a deposit of callus and some conse- 
quent osseous adhesion of the humerus to the ulna." 

12. The first case quoted on page 432 from Dr. Hodges's second paper, 
one of multiple fractures at the elbow, fractures of the head of the radius, 
the olecranon, and the coronoid process. 

As regards experiment upon the cadaver we have the assertion of 
Malgaigne (Lvxations, p. 634), that in producing dislocations backward 
he broke off the end of the coronoid process quite frequently, and the 
more detailed results of Lotzbeck 2 who fixed the elbow in a slightly 
flexed position by means of a gypsum bandage and then by striking 
upon the palm of the hand broke the coronoid process five times in ten 
attempts. Varying the experiment by extending the elbow completely 
he succeeded in producing the fracture only once. 

The mechanism of this production and the anatomical relations of the 
process explain the union with slight displacement shown in some of the 
specimens and the difficulty of diagnosis during life. The tendon of the 
brachialis anticus is inserted not upon the tip of the process but upon its 
anterior aspect and base, and the articular capsule is attached all along 
its edge. When it is broken off by being forced backward against the 
trochlea its connection with the ulna is preserved in front by the tough 
attachments of the tendon, and therefore instead of being displaced 
bodily along the anterior aspect of the bone it is probably only tilted 
forward. Its vitality is assured in any case by its connection with the 
capsule, and when the dislocation is reduced the fragment is held 
exactly in place by the tendon of the brachialis anticus in front and the 
humerus behind. 

The clinical symptoms upon which the diagnosis has been usually 
made are a dislocation of the elbow backward, its easy reduction and 
easy reproduction, crepitation, and sometimes the presence of a small, 
hard movable body in the fold of the elbow in the line of the tendon of 
the brachialis anticus. 

So far as can be inferred from the few detailed descriptions of speci- 
mens the line of fracture crosses the process transversely or somewhat 
obliquely at about one-fourth of an inch below its apex, and may reunite 
with a close bony union as in Cases 3, 7, and probably 11, or by a fibrous 
band as in Case 1. When the union is close and bony there may be a 
somew T hat exuberant callus upon the anterior aspect of the process, due 
probably to the stripping up of the periosteum or tendon. 

The mechanism in the great majority of cases is by indirect violence 
exerted in such a way as to cause dislocation of the joint backward and 
to break oft' the point of the process as it is forced past the trochlea. 
In one case mentioned by Lotzbeck the process appeared to have been 
broken off' by direct violence ; a soldier was struck in the elbow by a 

1 Med. Times and Gazette, 1875, i. p. 576. 

2 Schmidt's Jahrbuch, vol. 129, 1866, p. 134. 



IN THE VICINITY OF THE ELBOW-JOINT. 431 

piece of a shell which caused a severe contusion but no open wound. 
Two months afterwards the coronoid process could be felt as a movable 
body, and by pressing it down it could be made to rub against the ulna 
with a creaking sound. Acupuncture proved the supposed fragment to 
be a hard solid body. 

In another case, that of a boy 14 years old, the process was broken 
off by extreme flexion of the elbow. A somewhat similar personal expe- 
rience may be mentioned as corroborative of this mechanism to a certain 
extent. I excised an elbow for suppurative disease of the joint, using 
Ollier's postero-lateral incision. In order to facilitate the cleaning of 
the external condyle, and before the olecranon had been touched, I 
asked the assistant to flex the elbow ; he did so with some force, and felt 
something snap. On examination, about half an inch of the coronoid 
process was found to have been broken off. It seemed to me, however, 
to be unusually long and prominent, possibly by ossification of the 
attached capsule in consequence of the prolonged inflammation. 

The symptoms and the means of diagnosis, in view of the uncertainty 
of the diagnosis in the supposed cases, cannot be positively described ; 
those which have been considered sufficient have been mentioned above : 
dislocation backward, easy reduction, great tendency to recurrence, pos- 
sibly crepitation, and the presence of a hard movable body in front of 
the elbow in the line of the tendon of the brachialis anticus. In the 
only case that has come under my observation, a case which I was 
invited to see by my friend and colleague, Dr. Keyes, the supposed 
fragment could be readily grasped between the thumb and finger and 
moved freely to and fro. 

The treatment consists in immobilization of the joint flexed to a right 
angle or beyond. The degree of flexion and the completeness of the 
immobilization may vary with the tendency to displacement. If the 
latter is great, experience has shown that it is best opposed by increasing 
the flexion, and of course complete immobilization gives additional 
security. A posterior or lateral splint or a plaster moulded one may be 
used. Velpeau recommended that the immobilization should be main- 
tained for at least four weeks and the opinion has been shared by many 
distinguished surgeons, but I think the practice Dr. Hamilton recom- 
mends is likely to be sufficient in most cases ; he advises the use of the 
splint for a week or ten days and then a simple sling. The guide in 
this matter will be the tendency to displacement ; when that ceases the 
splint becomes unnecessary, and the only indication is to maintain suffi- 
cient flexion to favor prompt and close union. The slight motion in the 
joint permitted by a sling, if it is painless, diminishes the resulting stiffness. 

3. Fractures of the Head and Neck of the Radius. — Our knowl- 
edge of this variety of fracture is drawn from about a dozen specimens 
and two or three doubtful cases. Partial fracture of the head of the 
radius in connection with fracture of the coronoid process of the ulna 
(fig. 236) is the form that has been most frequently observed. Five of 
the cases have been given in the preceding section (Cases 5, 6, 8, 9, and 
10, page 429), and in all the position and extent of the fracture seem to 
have been the same, crossing the articular surface transversely and ex- 
tending about half an inch down the neck, thus breaking off a fragment 



432 FRACTURES OF THE BONES OF THE FOREARM. 

which comprises the anterior third or fourth of the articular surface. Dr. 
Hamilton saw " in Dr. Mutter's cabinet two specimens of fracture of 
the outer half of the head of the radius. In one case the small fragment 
is slightly displaced downwards in the direction of the axis of the bone ; 
and in the other the fragment is thrown outwards, or to the radial side. 
Both are firmly united in their new positions." 

Dr. Hodges 1 presented to the Boston Society for Medical Improve- 
ment, Oct. 8, 1866, a specimen of fracture of the head of the radius 
taken from the body of a man who died a few hours after having fallen 
from a height of sixty feet. Although there was but little swelling, and 
the conditions were exceptionally favorable for the examination, the frac- 
ture was not recognized during life. The autopsy revealed a " longitu- 
dinal fracture of the head of the radius. The specimen presented a 
clear and regular split involving very nearly one-half the head of the 
radius, cleaving outwards so as to extend no further than the neck of the 
bone. It was accompanied by a very oblique fracture of the shaft of the 
ulna, commencing at the depression of the articular surface marking the 
separation of the coronoid process and the olecranon, extending almost 
longitudinally three and a quarter inches downwards, and detaching 
from the shaft that portion of the bone to which the olecranon was 
attached." Dr. Hodges refers to reported cases of similar fracture of 
the radius associated with fracture of the coronoid process, and points 
out their close resemblance to this one, since a slight deviation of the 
line of fracture would have separated the coronoid process at its base. 

In a subsequent paper he reports 2 five additional cases: (1) A man, forty 
years old, fell from a height of forty feet and received a compound frac- 
ture of the elbow. The head of the radius was split into two unequal 
parts, neither of which was completely detached ; the olecranon and 
coronoid process were broken from the ulna. (2) A man, twenty-four 
years old, fell against some machinery in motion and received a com- 
pound fracture of the elbow, the external condyle of the humerus and 
one-third of the head of the radius being broken off. (3) A speci- 
men in the Warren Museum without history, No. 1023. Fracture of 
the shaft of the radius. " Upon the head of the bone is a small fragment 
f inch in diameter, chipped, as it were, from the articulating surface. 
The fragment has a well defined outline, and is united in place without 
any signs of new growth of bone around it." (4) A man, fifty -five 
years old, received a compound comminuted fracture of the elbow by 
the fall of a mass of stone upon it. Excision. The head, neck, and 
shaft of the radius were split for 1J inches into three pieces, and the 
external condyle of the humerus broken off'. (5) A gunshot fracture 
similar to the last. 

Dr. Hamilton quotes the description furnished him by Dr. Mutter of 
a specimen of fracture of the " neck of the left radius just at the upper 
extremity of the bicipital protuberance" in the latter's cabinet, and adds 
a drawing of the same (fig. 237). The fracture has united with deform- 
ity, the articulating surface facing backward and its anterior edge lying 
in contact with the humerus. 

1 Boston Med. and Surg. Journal, 1866, vol. lxxv. p. 383. 

2 Boston Med. and Surg. Journal, 1877, vol. xcvi. p. 65. 



IN THE VICINITY OF THE ELBOW-JOINT. 



433 



Fig. 237. 



In a case that came under my own care the outer half of the head of 
the radius was broken by direct violence. The patient, a boy thirteen 
years old, was admitted to the Presbyterian Hospital, March, 1877, 
with suppurative arthritis of the right elbow following a blow received 
two months before ; a playmate had thrust 
at him with a sled, and the sharp end of the 
iron-shod runner had struck him upon the 
outer side of the elbow. I excised the joint, 
and in the course of the operation found the 
outer half of the head of the radius sepa- 
rated from the rest and from the shaft, with 
an irregular surface of fracture and preserva- 
tion of the articular cartilage . There was about 
half an ounce of thick brownish pus in the cav- 
ity of the joint, and the articular cartilage of 
the ulna was eroded and hanging in shreds. 

The symptoms were complete muscular fixa- 
tion of the joint at a right angle, swelling of 
the posterior and lateral regions of the joint, 
tenderness on pressure over the head of the 
radius and on movement ; rotation of forearm 
painful and very limited ; the skin was nor- 
mal, except for some reddening over the head 
of the radius. 

In another case the head of the radius was 
broken in a dislocation of both bones back- 
ward. The patient, a man twenty-seven years 
old, was admitted to the Presbyterian Hos- 
pital, April, 1882, with a backward disloca- 
tion of the right elbow, produced by a fall 
from a wagon upon the palm of the hand. I 
reduced the dislocation under ether, and then 
felt a movable piece of bone on the outer side between the olecranon 
and the head of the radius. As the olecranon, external condyle, and 
accessible portion of the radius appeared uninjured, I thought it must 
be a fragment from the inner side of the head of the radius and removed 
it with antiseptic precautions. It was part of the head of the radius, 
about one-third. 

Dr. W. R. Townsend treated a case of supposed fracture of the head 
and neck of the radius in Belle vue Hospital in 1881. The patient was 
a stout, muscular man, thirty-nine years old, who fell from a ladder, 
striking upon the outer side of his left arm, which was held close to his 
body. After the swelling had subsided a movable piece of bone could 
be felt at the side of the head of the radius ; crepitus could be felt 
when the wrist was rotated. The diagnosis was confirmed by Drs. Mc- 
Burney and Yale. I saw him a year later, in April, 1882 ; flexion of 
the left elbow w T as complete ; extension incomplete, to about 140°; pro- 
nation and supination limited to about 90° ; some pain in damp weather. 
The head of the radius is very irregular, its diameter greater than usual, 
and the distance from its upper edge to the top of the olecranon nearlv 
28 




Fracture of the neck of the ra- 
dius ; union with displacement, 
a, articular surface. (Hamilton.) 



434 FRACTURES OF THE BONES OF THE FOREARM. 

an inch greater than on the right side. The prominent upper part of the 
head of the radius moves nearly an inch on rotation of the wrist. The 
edge of the outer condyle of the humerus feels a little irregular. The 
arm was strong and useful, and the patient had returned to duty in the 
fire department as steersman of a hook and ladder truck. 

In the few supposed cases that have been reported the diagnosis has 
either been overthrown by the autopsy, or is so uncertain that but little 
value can be attached to the symptoms upon which it was based. In 
three supposed cases seen by Dr. Hamilton at periods varying from ten 
weeks to fifteen months after the accident, a bony projection could be felt 
in front of the elbow at a point corresponding to the radius, and there 
was almost complete loss of motion. On theoretical grounds I should 
hope to obtain crepitation in a case of partial fracture of the head by 
making pressure upon it with the finger, and rotating the wrist gently. 
The same exploration might yield the same result after complete fracture 
of the neck, or even demonstrate the independent mobility of the shaft. 

Moore 1 reported a case of " fracture of the neck of the radius," ob- 
served by himself three years after the receipt of the injury, but the 
fracture was evidently below the insertion of the biceps. Some of the 
details may be found in the section on Fractures of the Shaft of the 
Radius (page 444). 

While the cases are too few in number to establish the prognosis defi- 
nitely, they show two possible results : union, and chronic inflammation 
of the joint. Mutter's three specimens show that repair is possible; the 
means by which it is produced may be doubtful, but probably the peri- 
osteum of the neck remains untorn and keeps up vascular communica- 
tion between the shaft and the fragment. Moreover, as has been stated 
elsewhere, even if the fragment should be entirely severed, it is not im- 
possible for new communications to be established and bony union to 
follow. In my first case disorganization of the joint, suppurative arthritis, 
followed and rendered excision necessary ; this patient was a delicate, 
strumous lad. In only one of the remaining cases not operated upon, Vel- 
peau's, did the patient survive the injury for more than a few hours, and 
in the report of this no mention is made of the existence or absence of 
repair. After complete fracture of the neck above the bicipital tube- 
rosity the biceps might be expected to draw the upper end of the shaft 
forward, and this is the explanation which Dr. Hamilton suggests of the 
deformity in the three cases observed by him. In Mutter's specimen of 
fracture of the neck repair appears to have taken place with marked 
angular displacement in this direction. 

Treatment after partial fracture of the head will be regulated by the 
fracture of the coronoid process or ulna with which it has been asso- 
ciated in all the recorded cases ; if the fracture of the radius should be 
recognized, or even strongly suspected, I should make immobilization 
more complete, and maintain it for a longer time than in simple fracture 
of the coronoid process, because the vitality of the fragment can be 
preserved or regained only by the spread into it of granulations coming 

1 London Med. Gazette, 1S45, vol. xxxvi. p. 1079. 



FRACTURES OF THE SHAFT. 435 

from the main portion, and the more perfect the quiet, the more probable 
would be the accomplishment of this desired result. 

After complete fracture of the neck the elbow should be immobilized 
at a right angle for at least four weeks, and forcible passive motion 
should not be made until after consolidation is thought to be complete. 

B. Fractures of the Shaft. 

1. Fractures of the Shafts of both Bones. — The relative fre- 
quency of fracture of both bones may be seen by reference to the table 
given in Chapter XIX. It occurs rarely in the upper third ; according 
to Hamilton only 6 times in a total of 73, 31 being in the middle third, 
and 35 in the lower third. Usually the radius is broken nearer the 
elbow than the ulna. 

Direct violence is a frequent, according to some the most frequent, 
cause of the fracture, the limb being broken by a blow, by the passage 
of a wheel, or by a fall against some object. Fractures by indirect 
violence are caused by falls upon the hand, and while fractures of the 
radius alone are the more common result of this accident, yet both 
bones may be broken, and in some cases it seems clear that the fracture 
of the ulna follows, and is in a measure the consequence of that of the 
radius. 

Only a few instances of fracture by muscular action have been re- 
corded. Malgaigne reports a case in which a healthy robust lunatic 38 
years old, broke both bones while shovelling. As he sought to raise the 
shovel with its charge of earth, he heard two distinct snaps in his right 
forearm, and was unable to continue his work. The next day Malgaigne 
found a fracture of the radius near its centre and one of the ulna about 
an inch nearer the wrist, with considerable displacement. Velpeau 1 
reports a similar case, the patient being a large strong man, and Grurlt 2 
one communicated to him by Ulrich of a healthy woman, 37 years old, 
who broke both bones of the forearm and the fifth metacarpal bone by 
rising in bed and supporting herself upon the hand on the third day 
after her fifth normal confinement. 

Partial or incomplete fractures, " green-stick fractures," are, accord- 
ing to Malgaigne, more common in the forearm than elsewhere, and are 
usually due to a fall upon the hand. My personal experience is limited 
to a very few cases, and although I have not been able to obtain very 
definite descriptions of the accidents from the youthful patients or their 
attendants, it has seemed probable that the fractures were caused rather 
by the arm being caught and twisted under the body than by direct im- 
pact upon the hand. In one case the patient, a large muscular lad 18 
years old, was caught in machinery and had his left arm twisted about 
a reel or shaft. There was marked angular displacement at the junction 
of the lower and middle thirds of the forearm, the lower segment being 
inclined sharply forward. Rotation diminished; pain on pressure at the 
angle. By placing my knee against the projecting part and drawing 

1 Gazette des Hopitciux, 1850, p. 76. Quoted by Grurlt. 

2 Loc. cit., vol. i. p. 244. 



436 FRACTURES OF THE BONES OF THE FOREARM. 

back forcibly upon the wrist and elbow I was able to reduce the displace- 
ment almost entirely. There was no crepitus, and no mobility. The 
humerus was broken at its middle. 

The line of fracture is either smoothly oblique or transverse with large 
serrations, and in other respects may show the varieties observed in the 
fractures of other long bones, such as splintering, comminution, and 
multiplicity of fracture. In a specimen preserved in the Museum of 
Bellevue Hospital there are two fractures of each bone ; one pair, com- 
plete, in the middle third, the other pair, incomplete, infractions, close 
by the wrist. There was also a fracture of the humerus ; the limb was 
removed by amputation. 

The displacements are of the usual kinds : overriding in oblique frac- 
tures, lateral with or without overriding in the transverse fractures, and 
angular displacement of one or both bones in both forms. Rotatory dis- 
placement of the radius alone, especially when it is broken above the 
insertion of the pronator teres, was first pointed out apparently by Lons- 
dale. He suggested that the upper fragment might be strongly supinated 
by the biceps, while the lower fragment was kept in the usual semi-prone 
position, and he thought this might be a cause of the inability to supinate 
the hand completely, sometimes observed after fracture. Flower and 
Hulke 1 say they have found proof of the correctness of this conjecture 
in the examination of numerous specimens of united fracture of the 
radius, "in a great number of which the lower fragment was much less 
supinated than the upper, 5 ' and Agnew says there are similar specimens 
in the collections of the College of Physicians and the University of 
Pennsylvania. Mr. Callender 2 examined 18 specimens of united fracture 
of the shaft of the radius in the London Museum, and found in 15 of them 
rotatory displacement averaging 36°, the extremes being 6° and 64°. 
The displacement in every case was that pointed out by Lonsdale, supi- 
nation of the upper fragment. 

In angular displacement one bone may be sharply bent in towards the 
other, which remains nearly straight, or the fragments of both bones 
may be inclined in the same direction, forward, backward, or to either 
side, or there maybe lateral inclination in opposite directions, each bone 
being inclined towards the other ; and if the fractures are on the same 
level the four ends may thus be brought into contact, and the possibility 
created of a union that will abolish the power of rotation of the limb. 
In the case quoted above from Malgaigne, the lunatic who broke his arm 
while shovelling, the ends of the upper fragments were brought together 
and interposed between the ends of the lower fragments, and in addition 
there was a displacement produced by supination of the lower segment 
of the limb, one which brought the lower fragment of the radius behind 
the upper one, and that of the ulna in front of its upper one. A dis- 
placement, the direct opposite of the latter, has also been observed and 
described by Malgaigne, the lower segment of the limb being more pro- 
nated than the upper one. Overriding of the fragments has been ob- 
served to a distance of more than three inches (eight centimetres). 

1 Holmes's System of Surgery, Am. ed., vol. i. p. 860. 

2 St. Bartholomew's Hospital Reports, vol. i. 1865, p. 297. 



FRACTURES OF THE SHAFT. 437 

The symptoms are the usual ones of fracture ; pain, deformity, abnor- 
mal mobility, crepitation, and loss of power. 

The course is usually simple and the prognosis favorable, but both 
may be gravely modified by laceration or bruising of the soft parts or 
by the occurrence of acute inflammatory reaction or of gangrene, and 
in addition the prognosis may be made unfavorable by an irreducible 
displacement or comminution or loss of substance of one of the bones. 
Displacement affects the prognosis when it increases the chances that 
union may take place between the two bones, and comminution or loss 
of substance by favoring the occurrence of pseudarthrosis. 

In simple cases without marked displacement or complication com- 
plete union may be expected in a month, but in no other limb do inflam- 
matory complications and gangrene occur so frequently, even under 
prudent treatment. The gangrene may be limited to points where the 
splints have made pressure or to portions of the hand and fingers, but 
it is very likely to involve the entire member if it is overlooked at the 
beginning or not effectively combated. Diffuse phlegmonous inflamma- 
tion of the forearm may follow severe bruising of the soft parts or may 
even take its rise in the fracture. Its importance lies in the danger 
to the life and limb which follows the burrowing of the pus, the openings 
which it necessitates, and the matting together of the tendons and their 
sheaths. Demarquay says he has often seen muscular atrophy follow 
fracture of the forearm, the result of this inflammatory process, and 
while writing this section I was consulted in a case of such atrophy and 
limitation of the movements of the finders due to inflammation following 
a simple fracture of both bones by direct violence. 

The cause of the gangrene in many cases has been pressure exerted 
by splints or bandages, and the necessity for caution and watchfulness 
to avoid this accident cannot be urged too strongly. The practice of 
applying a roller bandage to the limb under the splints is extremely 
dangerous, and so also is the use of splints of soft material, pasteboard 
and the like, which take the shape of the limb and are fastened to it 
with a roller bandage. There is the same compression, the same chance 
of strangulation in this case as when the roller is applied directly to the 
skin. It is not safe to depend upon the sensations of the patient, upon 
pain, to give warning of threatening strangulation ; cases, in both old 
and young, have been reported in which total gangrene of the distal 
portion of the limb has occurred without attracting the attention of the 
patient or his attendants by any symptoms except the final change in 
the color of the exposed fingers. Dr. Hamilton gives a number of illus- 
trative examples, of which I reproduce the following ; in two of them the 
gangrene may be fairly attributed to the dressing, and in the third 
probably to the bruising of the soft parts by the original violence sup- 
plemented by the pressure of the splints which became excessive when 
the limb swelled. 

1. A child 2 \ years old fell from a chair to the floor, breaking both 
bones of the left forearm near the middle. A physician applied a roller 
bandage from the fingers to the elbow, and over this three light narrow 
wooden splints, one in front, one behind, and one on the radial side, and 
bound the whole together by another roller. The child continued to 



438 FRACTURES OF THE BONES OF THE FOREARM. 

play about, and ten days afterwards the doctor noticed that the ulnar 
side of the little finger was blue. The bandages were immediately 
removed and never again applied tightly. 

Three or four days later the gangrene had extended over the whole 
of the little finger and most of the thumb, and there were gangrenous 
spots over the hand and forearm extending to within one inch from the 
elbow-joint ; these spots seemed to correspond to the pressure of the 
splints. The hand was much swollen, and also the arm above the line 
of the gangrene. The sloughs had already begun to separate, and the 
gangrene was extending at only a few points. The child appeared well. 
The arm and a large portion of the hand were saved. 

2. A young man, 20 years old, suffered a simple fracture of the right 
radius and ulna, which was dressed on the same day with a roller next 
to the skin and over this the splints. On the next day the fingers were 
black, but the dressings were not removed until the third clay when he 
was admitted to Bellevue Hospital. There had been no pain after the 
first few hours. Three weeks afterwards he was seen by Dr. Hamilton 
and had then lost all the fingers and part of the thumb, and there were 
extensive suppuration and sloughing along the forearm. He died a few 
days afterwards. 

3. A young man, 22 years old, was admitted to Bellevue Hospital 
with a fracture of the left forearm near its middle, caused by the kick 
of a horse on the preceding day. The fracture was dressed with pro- 
perly padded palmar and dorsal splints secured with a roller which 
included the hand and forearm, and the arm placed in a sling. On the 
third day he was walking in the yard when the surgeon's visit was made 
and was not seen by him. On the fourth day "he was apparently in 
perfect health, but as I stopped him a moment to look at his arm, I saw 
that the hand was swollen and purple. The dressings were immediately 
removed and the patient placed in bed. There were upon the arm two 
spots looking like superficial sloughs. He was suffering no pain. The 
gangrene subsequently extended until it involved a large portion of the 
hand and forearm, and on the eighteenth day after the receipt of the 
injury he died." 

The possibility of union between the bones as well as the fragments 
should always be borne in mind. Its occurrence is more likely when 
the natural interval between them is destroyed or diminished by dis- 
placement, but this approximation is not essential. Excessive formation 
of callus, in consequence of laceration of the intermediate tissues and 
irritation especially of the interosseous membrane, is sufficient in itself 
to produce this result so destructive of the usefulness of the limb. The 
occurrence is favored also by correspondence in the position of the frac- 
tures, for the fragments are more likely to fall into abnormal contact 
with each other, and the granulations which form the callus 'about each 
fracture may easily unite if each spreads over only half the intermediate 
space (fig. 238). It has occasionally happened that the two calluses 
have come into contact and formed a lateral joint (fig. 239) instead of 
uniting. Such a specimen is said by Callender to be in the Museum of 
King's College. In other cases, again, rotation is diminished or abol- 
ished by union of one or both fractures at an angle, as in either of these 



FRACTURES OF THE SHAFT 



439 



figures. 



Slight inclination of the hand to one side or the other is a not 
infrequent result and may be due to the position of the sling in which 
the arm is supported ; thus, if the weight of the arm is borne upon the 
sling at or above the point of fracture the unsupported hand drops down- 



Fig. 238. 



Fig. 239. 





Fracture of the forearm, angular displacement, 
and union between the bones. 



Fracture of the forearm, with formation 
of a lateral joint. 



ward and the lower fragment deviates toward the ulnar side, as in the 
figures ; while if the sling passes under the hand or wrist and leaves 
the forearm unsupported the latter sinks down between the wrist and 
elbow and the lower fragment deviates in the opposite direction toward 
the radial side. 

Delay or failure of union of either or both bones is not uncommon, 
and cases are reported in which the union of one of the bones has been 
delayed four or five months, and has then taken place without operative 
aid. Failure of union entails a disability that is practically complete, 
and Agnew's tables do not indicate that the prospects of relieving it by 
operation are very great, since out of thirty-seven cases a cure was ob- 
tained in only nineteen. Malgaigne says that he had seen in two cases 
rotation destroyed apparently by union of the upper fragments of the 
two bones, and solidity of the limb lost by the failure of union between 
the upper and lower fragments. 

Treatment. — Reduction must be effected, when necessary, by exten- 
sion and counter- extension aided by cautious pressure upon the bones 
near the seat of fracture. The importance of reduction is exceptionally 
great, because of the special function of rotation of the forearm which 
may be so easily destroyed by displacement. Overriding is to be over- 



440 FRACTURES OF THE BONES OF THE FOREARM. 

come by extension ; the forearm and fingers are flexed, counter-exten- 
sion is made by an assistant who grasps the arm close above the elbow, 
and extension by the surgeon himself or another assistant grasping the 
hand. If there is angular displacement the extension should first be 
made in the direction of the lower fragment, and when this is thought to 
be sufficient, and while it is still maintained, the lower segment of the 
limb is brought into line with the upper one, the latter being steadied 
by the hand of the surgeon or pressure being made upon the projecting 
angle with the thumbs. This pressure may be safely made if the angle 
is directed forward or backward, but it must be used with great caution 
when the angle is lateral, for there is danger that it may force the bone 
upon which it is made too near its fellow, and that when the manoeuvre 
is completed the position of the fragments may resemble that of the 
arms of an X-> eacn P a i r being displaced angularly toward the other. 
To avoid this result, which if left uncorrected is full of danger to the 
future usefulness of the limb, the hand should be supinated while reduc- 
tion is making, because in this position the interval between the bones 
at the centre of the limb is greatest and most accessible, and the sur- 
geon should seek to force or keep the fragments apart by pressing his 
thumbs in between them in front and his fingers behind. 

The position in which the forearm is usually kept during treatment is 
that w r hich is midway between pronation and supination. It is the one 
which the limb naturally assumes when it is suspended beside the body 
with the elbow bent at a right angle and is the one which is borne with 
the least fatigue and discomfort. But while this position meets the in- 
dications sufficiently in the simple and, indeed, in most cases, it was long 
since recognized by some surgeons that the bones of the forearm are 
normally separated most widely from each other at the centre when the 
limb is supinated, and that consequently this position is the one in which 
the arm should be kept whenever there appears to be danger of the 
bones uniting with each other. According to Malgaigne, fractures of 
the forearm were treated in the supine position by the contemporaries 
of Hippocrates, but the practice was condemned by that writer ; it 
was reinvented by Pare, and abandoned by him when he learned that 
Hippocrates had disapproved of it, a yielding to authority that seems to 
have been unusual with that vigorous-minded surgeon, and again rein- 
vented by Malgaigne, who afterwards learned that Lonsdale had pre- 
ceded him by a few years. Lonsdale 1 recommended the position for a 
reason mentioned above, the difference between the degree of supination 
of the upper fragment of the radius and that of its lower fragment ; 
Malgaigne recommended it because of the greater distance between the 
centres of the bones when they are in this position. The objection to it 
is the greater constraint and inconvenience of the position, an objection 
which of course should not be allowed to weigh for a moment against a 
serious risk of faulty union, and which, if it becomes great, should be 
met by rest in bed with the arm abducted and the elbow flexed at a 
right angle ; in full supination the hand then rests easily on its ulnar 
border with the thumb directed upward. 

London Med. Gazette, 1832, vol. ix. p. 910. 



FRACTURES OF THE SHAFT. 441 

The accepted method of treatment is to fix the limb between two 
light wooden splints broad enough to overlap it slightly when applied to 
the palmar and dorsal surfaces. The palmar splint should extend from 
the fold of the elbow to the roots of the fingers, the dorsal one should 
be shorter and not reach beyond the wrist. Each splint should be 
padded with cotton, and patients usually find it agreeable to have the 
end corresponding to the palm of the hand very thickly padded, or a 
small roll of bandage fastened obliquely to it so that the fingers can close 
easily over it. Dr. Hamilton recommends that the padding at the pal- 
mar surface of the wrist and just above it should be intermitted or made 
very thin so as to avoid painful pressure upon the median nerve. 

In simple cases uncomplicated by threatening displacement, the splints 
are applied to the semi-pronated limb and fastened by two strips of ad- 
hesive plaster wrapped about them, one near the elbow, the other at the 
wrist, the hand is made fast to the palmar splint by a few turns of a 
badage, and the limb is placed in a sling that supports both the elbow 
and hand. 

In other cases where the fragment threatens to encroach upon the 
interosseous space the splints must be applied with the limb supinated, 
and it is proper to employ a device introduced by Jean Louis Petit to 
force or keep the bones apart, although there is reason to doubt if it is 
very efficient. He sought to keep the fragments apart by making pres- 
sure between them with graduated compresses placed longitudinally 
under the splints. Malgaigne has pointed out very clearly the difficul- 
ties in the way of making effective pressure by this means, and has shown 
that the pads, if used at all, should be very short, not more than an inch 
or two in length, and placed at the centre of the arm where the interval 
between the bones is greatest. Other surgeons, Dr. Hamilton among 
them, are satisfied with the pressure of the muscles pushed back by flat 
or padded splints. ISelaton used corks instead of pads. Dr. E. T. 
Caswell 1 says of these pads that " if useful they are intolerable ; if 
tolerable they are useless." If the supine position of the forearm 
proves inconvenient and troublesome, that of semi-pronation may be 
safely substituted after repair has fairly begun, say at the end of a 
week or ten days. 

In either case the limb should be frequently inspected, daily for the 
first few days, in order to guard against excessive pressure either by 
bandages too tightly applied at first, or made too tight by the swelling 
of the parts, and to detect and remedy any new displacement. 

A roller bandage should not be applied to the limb under the splints ; 
it can answer no good purpose, and it exposes to displacement by press- 
ing the fragments toward each other, and to gangrene by constriction of 
the limb. The plaster-of- Paris dressing is equally objectionable for the 
same reasons during the first few days, and is to be avoided afterwards 
because it prevents inspection of the parts. 

The anterior and posterior splints immobilize the limb sufficiently to 
meet every indication except that of opposing the tonicity of the muscles 
and the occurrence of overriding. When the lines of fracture are trans- 

1 Holmes's System of Surgery, Am. ed., vol. i. p. 861. 



442 



FRACTURES OF THE BONES OF THE FOREARM. 



verse or toothed, the bones themselves afford sufficient protection, but 
when the fracture is oblique it is probable that repair will be accompa- 
nied by some shortening. This in itself would not have much importance, 
but if the transverse displacement which must accompany it is lateral, 
it may reduce the breadth of the interosseous space sufficiently to dimin- 
ish rotation, or may even lead to lateral union of the bones. The lack 
of fixed points makes it difficult to oppose this tendency by means of the 
straight splints alone, and various plans have been suggested for making 
counter-extension upon the arm by means of an angular splint; the other 
fixed point is obtained by binding the hand and wrist to the other end 
of the splint. Figure 240 represents a splint used by Dr. X. C. Scott 

Fig. 240. 




Dr. Scott's splint for fracture of the forearm. 

in a number of cases with good results ; the extension is made by means 
of adhesive plaster secured to the hand and wrist. 

In compound fractures great caution should be used in removing frag- 
ments or excising portions of bone, lest failure of union should follow. 
If the extent and position of the wound are such that efficient splints 
cannot be used at first, the patient should be kept in bed with the arm 
abducted and the elbow flexed, and extension, elastic or by weight, made 
by means of adhesive plaster attached to the hand and wrist. Counter- 
extension can be made from the lower part of the arm by a broad band- 
age, or from the upper part of the forearm by adhesive plaster, the limb 
being meanwhile supported upon cushions or suspended, and preferably 
steadied by a splint placed outside the dressings of the wound. 

2. Fracture of the Shaft of the Ulna. — Fractures of the shaft 
of the ulna alone are almost invariably the result of direct violence, of 
a blow received upon the arm while it is raised to protect the head, or 
of a fall upon the ulnar side of the forearm. A case of fracture by 
muscular action is quoted in Chapter IV. p. 96. 

Agnew states that of 88 cases treated in the Pennsylvania Hospital 
27 were fractures of the upper third, 32 of the middle third, and 29 of 
the lower third. He mentions also the frequency, about 28 per cent., 



FRACTURES OF THE SHAFT OF THE ULNA. 443 

of comminution, simple or compound, and Dr. Hamilton says that in his 
experience serious complications are more frequently associated with 
fractures of this bone than with those of any other; of 36 cases observed 
by him 4 were compound, 12 complicated with dislocation of the head 
of the radius, and 1 each with dislocation of the elbow backward and 
dislocation of the lower end of the radius. 

Displacement may be entirely absent, and when present may be in 
any direction. Its extent and direction seem to depend almost entirely 
upon the fracturing force. Most recent writers, following the example 
of Pouteau, 1 have alleged that the broad articulation of the ulna with 
the humerus prevented lateral displacement of the upper fragment, and 
that the lower fragment was therefore the only one that could be dis- 
placed towards the radius. Even if the articulation was absolutely free 
from lateral mobility, the inference that has been thus drawn would not 
be correct, because the radius can be moved towards the ulna after frac- 
ture of the latter and thus the exact equivalent of the displacement of 
the ulna towards the radius produced. The only muscle which acts 
directly upon the lower fragment is the pronator quadratus, the tendency 
of which is to draw it towards the radius. 

The symptoms may be limited to pain and swelling at the seat of frac- 
ture, and their significance may be rendered obscure by the history and 
the effect upon the soft parts of the direct violence which has caused the 
fracture. If the radius remains entire and is not dislocated at either 
end, there can be no shortening of the limb, no overriding of the frag- 
ments, and displacement, if present, must be recognized by following the 
outline of the bone with the finger. Fortunately this exploration is made 
easy by the subcutaneous position of the ulna. Crepitus and abnormal 
mobility may be obtained by grasping the limb above and below the 
fracture and making pressure alternately upon the fragments with the 
fingers, or by seizing the fragments between the thumb and fingers and 
moving them forward and backward upon each other. 

The prognosis is good as regards repair and preservation of function, 
although failure or delay of union is said by Dr. Agnew to be more 
common than in the radius, and displacement of the fragments tow T ards 
the radius involves the possibility of loss of the powder of rotation of the 
wrist. Dr. Hamilton mentions a fact which is of much prognostic impor- 
tance unless his experience is entirely exceptional ; he says (loc. cit., p. 
334) : " I have seen the radius left unreduced nine times after fracture 
of the ulna, and in each example the forearm was shortened." He 
refers to dislocation of the head of the radius forward. 

Reduction can be made only by appropriate pressure upon the dis- 
placed fragments, extension being practically without value. The dis- 
placement which it is most important to overcome is the lateral one 
towards the radius, and that should be met in the same way as after 
fracture of both bones, that is, by pressing the thumb and fingers in 
between the bones. 

As the radius acts as a splint to prevent overriding of the fragments 
the surgeon's chief care is to secure immobility and prevent lateral or 

1 (Euvres posthumes, 1783, vol. ii. p. 258. 



444 FRACTURES OF THE BONES OF THE FOREARM. 

angular displacement. This can be done by the anterior and posterior 
splints used in fracture of both bones, or by a rectangular splint fastened 
against the inner side of the arm and semi-pronated forearm, or by a 
moulded plaster splint. In some cases it may be necessary to keep the 
forearm supinated, and in others the bruising of the soft parts may be so 
severe as to forbid the use of splints at first and require rest with cooling 
applications for several days. The arm should be kept in a sling and 
the same precautions should be taken to avoid undue pressure by the 
filing upon the ulna as when both bones have been broken. Many sur- 
geons place the limb in a pasteboard, felt, or plaster gutter in order to 
avoid this danger. In case of need an interosseous compress may be 
used under the anterior and posterior splints to keep the fragments away 
from the radius. 

3. Fracture of the Shaft of the Radius. — As far as can be judged 
from general impressions and statistics that are somewhat scanty, isolated 
fracture of the shaft of the radius is even less frequent than that of the 
ulna, and appears also to be generally caused by direct violence, some- 
times by a fall upon the hand, especially if at the same time dislocation 
of the lower end of the ulna takes place. An instance of fracture in the 
lower third by muscular action is quoted in Chapter IV. page 96. 

The displacements vary somewhat with the point at which the frac- 
ture takes place, the causes of the displacement being the fracturing 
cause, and the action of the biceps and pronator muscles. In a case 
reported by -T. Moore 1 as " fracture of the neck of the radius" but of 
which he says " the fracture appeared to have commenced just inferiorly 
to the insertion of the biceps tendon, and to have extended upwards and 
backwards through its neck," the upper fragment, which was one and a 
quarter inches long, was drawn upward by the biceps and the lower 
fragment had united with it at almost a right angle. The patient was a 
girl 24 years old, and the fracture was caused by a fall from a stool, a 
compound fracture of the ulna in its lower third was produced at the 
same time and the fracture of the radius was overlooked. Doubtless the 
fracture of the ulna united with shortening and thus made union of the 
radius with angular displacement possible. The case properly belongs 
among fractures of both bones, and is mentioned here only as a demon- 
stration of the action of the biceps. 

The fragments may be displaced in any direction, but the more common 
displacement appears to be an angular one, the apex of the angle being 
directed forward and towards the ulna. Figure 241 shows displacement 
of the upper end of the lower fragment alone towards the ulna, the 
fragments turn upon the lower radio-ulnar joint as a hinge with the 
effect of raising the styloid process of the radius to the level of that of 
the ulna, and of changing the direction of the lower articular surface of 
the radius so that the hand is inclined toward the radial side. This dis- 
placement is much more marked in figure 242, since there the fracture 
is at a lower point, only two inches above the end of the bone. In this 
case it is true that both bones have been broken, but as the ulna has 

1 London Med. Gazette, vol. xxxvi. 1845, p. 1079. 



FRACTURES OF THE SHAFT OF THE RADIUS, 



445 



united without displacement its fracture has had no share in producing 
displacement of the radius. The higher the fracture the less is the 
change in the direction of the lower articular surface, but the possibility 
of the loss of the power of rotation of the wrist is the same since it 
depends on the approximation of the shafts of the two bones. 



Fig. 241. 



Fig. 242. 





Fracture of the shaft of the radius. 
(Malgaigne.) 



Fracture of radius and ulna, displacement upward of 
the lower fragment of the radius. (Malgaigne.) 



The possible loss of supination in consequence of union with a rotatory 
displacement, the upper fragment being completely supinated by the 
biceps while the lower is kept partly pronated by the dressings, which 
was pointed out by Lonsdale, and has been spoken of in the section on 
fracture of both bones, is also to be borne in mind after fracture of the 
radius alone, especially if the seat of fracture is above the insertion of 
the pronator teres, and is to be met in the same manner, that is, by 
keeping the forearm supinated. 

If the fracture is at or below the middle of the bone the tendency of 
the biceps and pronator teres is to draw the lower end of the upper frag- 
ment forward and inward, and that of the pronator quadratus and supinator 
longus is to draw the upper end of the lower fragment towards the ulna. 

Overriding has been observed only when dislocation of the lower end 
of the ulna is associated with the fracture as in figure 242. Malgaigne 
indeed speaks of the change in angular displacement as a partial over- 
riding, but he admits that the use of the term is perhaps improper. 

The diagnosis is made by recognition of the displacement, if it exists, 



446 FRACTURES OF THE BONES OF THE FOREARM. 

of crepitation and abnormal mobility obtained by grasping the fragments 
with either hand and moving them upon each other or by placing a 
thumb upon the head of the radius and rotating the wrist gently. 

The indications for treatment are the same as after fracture of both 
bones, except so far as the uninjured ulna may be utilized as a splint or 
as its dislocation may require more or less prolonged extension. If dis- 
placement exists the fragments should be pressed back into place as before 
described, and if the fracture is low down and the lower fragment is in- 
clined toward the ulna it will perhaps be found easier to bring it back 
into line by drawing the hand forcibly downward and toward the ulnar 
side than by pressing the fingers in between the bones. Extension and 
counter extension at the wrist and elbow may be required to overcome 
dislocation of the lower fragment upward from the ulna. 

The arm should be secured upon well-padded anterior and posterior 
wooden splints in the semi-pronated position if the fracture is below the 
middle and the tendency to displacement is slight, or upon a posterior 
splint and supinated if the fracture is high up. Dislocation at the lower 
radio-ulnar articulation or change in the direction of the lower articular 
surface of the radius may make it desirable to use a moulded splint that 
will include the hand and perhaps the lower part of the arm, or a long 
rectangular one for the purpose of extension and counter-extension, or to 
keep the hand inclined toward the ulnar side. 

C. Fractures in the Vicinity of the Wrist. 

1. Fracture of the Radius. Colles's Fracture. — Under this 
term are included fractures of the radius near the wrist, which, while 
differing from each other in many respects, have in common a charac- 
teristic deformity, and often a certain difficulty in making and maintain- 
ing reduction. 

With possibly one exception, the outer half of the clavicle, the lower 
end of the radius is the part of the skeleton most frequently broken. 
While the fracture occurs at all ages, it is by far the most frequent in 
elderly women. It is very remarkable, and worthy of mention as a 
proof of the difficulty of diagnosis in fractures near a joint, as well as 
of the force of authority and tradition, that the real nature of this com- 
mon injury which comes so frequently under the notice of all surgeons 
should not have been recognized, and that it should have been taken 
always for a dislocation of the wrist backward, until about one hundred 
years ago. The first mention of the injury as a fracture is generally 
attributed to J. L. Petit, but, I think, incorrectly, for I find no refer- 
ence to it in his chapter on fractures, while the chapter on dislocation 
of the wrist contains a very good clinical description of it. 

Pouteau 1 is the first author to describe it as a fracture and to point 
out the previous universal error in diagnosis. He describes its pathology, 
attributes its production to the violent contraction of the pronators, and 
gives its symptoms and treatment, adding that there is, perhaps, no 
fracture so easy to recognize at a glance. The fact that he includes in 

1 GEuvres posthumes, 1783, vol. ii. p. 251. 



FRACTURES IN THE VICINITY OF THE WRIST. 447 

his description fractures of both bones does not, I think, diminish the 
credit due him for his recognition of the error of his predecessors and 
contemporaries. His view of the subject does not appear to have com- 
mended itself to his immediate successors, and, during the thirty years 
following its publication, only an occasional mention is made of even the 
possibility of such a lesion, and the common injury was still considered 
a dislocation. 

The next writer upon the subject failed in like manner to impress his 
opinion upon his immediate contemporaries, and although justice was 
ultimately done him, and the fracture is now known widely by his name, 
the recognition did not come until after bis death. Mr. Colles published 
his brief but accurate account of the fracture in 1814, 1 but Dr. R. W. 
Smith, writing in 1847 , 2 says : " Subsequent authors have repeated 
what Mr. Colles had said upwards of thirty years since, but no writer 
(as far as I have been able to ascertain), not even the distinguished 
author of the Surgieal Dictionary, has alluded to his account of the 
injury." 

Sir Astley Cooper, in the second edition of his Dislocations and 
Fractures of the Joints, published in 1823, describes fracture of the 
lower end of the radius, and adds that he had seen this injury fre- 
quently, but did not understand its nature until taught by dissection ; 
but he describes at the same time dislocation of the wrist, and evidently 
did not appreciate the full character and frequency of the fracture. In 
a subsequent edition he describes experiments made by himself upon the 
cadaver, in 1833, in w r hich he produced the fracture by hyper-extension 
(extreme dorsal flexion) of the hand. The same failure to appreciate 
the character of the common injury which was coming so frequently 
under the care of every surgeon persisted, notwithstanding the publica- 
tions of Pouteau and Colles, that of the former being entirely overlooked 
apparently, and that of the latter remembered only by the Dublin sur- 
geons, who believed in the fracture and gave his name to it. But the 
misapprehension was not destined to last long ; the great change which 
took place in the science of medicine at the beginning of the present 
century under the inspiration and guidance of the French physicians, 
the substitution of objective knowledge for dogma, of clinical and dead- 
house observation for pure speculation, made short work of this error. 
Dupuytren was the first to call attention to it and to impress it upon the 
profession ; a post-mortem examination in 1820 showed him the real 
character of the injury, and his hospital service gave him the clinical 
opportunities that were needed for study and demonstration. A short 
period of doubt followed, and then, about 1830, the fact was universally 
accepted, and the second stage — that of discussion of details, which has 
lasted until the present time — was entered upon. 

Mr. Colles, who had never had an opportunity to dissect a specimen 
of the fracture, speaks only of the symptoms and treatment. His only 
statement concerning the fracture itself is an incorrect one : " This 
fracture takes place at about an inch and a half above the carpal ex- 

1 Edinburgh Med. and Surg. Journal, April, 1814, vol. x. p. 182. 

2 Fractures in the Vicinity of Joints, Am. ed., p. 129. 



448 FRACTURES OF THE BONES OF THE FOREARM. 

tremity of the radius." We now know that, while the line of fracture 
may lie at the point he mentioned, it is usually much lower, and may be 
not further than a quarter of an inch from the articular edge of the bone. 
The average distance is differently estimated, possibly because some 
have measured from the articular edge of the bone and others from the 
styloid process ; but the weight of testimony places it at from one-third 
to three-fourths of an inch above the articular border. In young people 
it sometimes follows the epiphyseal line. Its direction is usually trans- 
verse, but it may be oblique laterally or antero-posteriorly, and the 
lower fragment may be comminuted. The lower fragment is sometimes 
displaced bodily backward without crushing, as in figures 243 and 244. 



Fie. 243. 



Fig. 244. 



Fig. 245. 






Fracture of the lower end of the 
radius. Displacement backward, 
(R. W. Smith.) 



Fracture of the lower end 
of the radius. Displacement 
of lower fragment backward. 



Fracture of the lower 
end of the radius Angu- 
lar displacement of the 
lower fragment backward 
with impaction. (R. W. 
Smith.) 



Sometimes the displacement is entirely angular, the lower fragment 
turning upon its anterior edge as upon a hinge, crushing or penetration 
with impaction takes place posteriorly and outwardly, and the articu- 
lating surface looks downward and backward instead of downward and 
forward as it does normally ; at the same time the styloid process rises 
to a higher level. An extreme example of this displacement, with 
union, is shown in figure 245. 

Specimens of recent fracture are not very common, and most of those 
we possess are open to the objection that the fractures have been caused 
by violence far in excess of that which causes the great majority of the 
fractures met with clinically, the patients having fallen from a consider- 
able height, and having received also injuries that caused death within a 
short time thereafter. The most interesting specimens are those obtained 
from elderly patients who have received the fracture in the usual man- 
ner, that is, by a fall upon the ground while walking, and have then died 



FRACTURES IN THE VICINITY OF THE WRIST 



449 



in a few days of an intercurrent affection, usually pneumonia. Such a 
specimen came into my possession in 1878 ; a woman, about fifty years 
of age, fell upon the sidewalk while walking, fractured the radius, and died 
within the week. The lower end of the bone was extensively commi- 
nuted for a distance of more than an inch, the articular surface being 
broken into four fragments (fig. 246). 

Malgaigne 1 describes and figures one observed by Maisonneuve ; the 
patient was a woman seventy years old, and died of pneumonia a fort- 



Fig. 246. 



Fig. 247. 





Keceut fracture of the radius, caused 
by a fail upon the hand. (Malgaigne.) 



Comminuted fracture of radial articular surface. 

night after the accident. The periosteum 
was uritorn on the posterior surface, and 
the styloid process of the ulna was broken 
off. The fracture was transverse, the dis- 
placement slight (fig. 247). The cause 
was a fall upon the hand. 

Mr. Cameron 2 had an opportunity to dis- 
sect two similar cases, both in elderly men 
dying of pneumonia soon after the injury. 
In one the fracture was oblique downward 
and forward, so that in front it was one-fourth of an inch above the articu- 
lar surface, and behind about one inch. In the other the fracture was 
transverse and about three-fourths of an inch above the articular surface. 
In front the fracture was hardly complete, and the periosteum was un- 
torn, while posteriorly there was firm impaction with splitting, the lower 
fragment being split into three pieces, which were nevertheless held 
firmly and securely together. 

A specimen obtained by Profs. McGraw and Walker, 3 of Detroit, de- 
serves, I think, to be classed with the others, although the fracture was 
caused by a fall from a height of twenty-five feet. The wrist presented 
the typical deformity. On dissection there was found no displacement of 
the ulna; no ligament was broken. There was a transverse fracture of 
the radius half an inch above the lower articular margin. iVnteriorly the 
fragments were separated about one-fourth of an inch ; posteriorly the 
compact wall of the upper fragment was driven into the cancellated tis- 
sue of the lower one so firmly that some force was needed to disengage 
them (fig. 248). The dorsal articular rim was broken oft' and divided 
into three pieces. The patient was a man sixty-two years old. 

In the specimens obtained after repair has taken place without reduc- 



29 



1 Loc. cit., vol. i. p. 606 ; and Atlas, pi. x. figs. 2, 3, and 4. 

2 Glasgow Med. Journal, March, 1878, p. 97. 

3 Annals of Anatomy and Surgery, March, 1831, p. 116. 



450 FRACTURES OF THE BONES OF THE FOREARM. 

tion of the displacement the penetration of the posterior portion appears 
very marked (fig. 249), more so often than it really is. The appear- 
ance is due in part to the formation of callus upon the posterior face of 
the upper fragment (fig. 250), under the periosteum, which is stripped 



Fig. 248. 



Fig. 249. 



Fig. 250. 




Impacted fracture 
of the lower end of 
the radius. (Annals 
of Anat. and Surg.) 




United fracture of the 
radius. (R. W. Smith.) 




Recently united fracture of the 
lower end of the radius. (R. W. 
Smith.) 



up, or torn by the displacement or crushing, the " periosteal bridge," 
which is found almost always upon one side of a fracture, and in part to 
condensation of the interior spongy tissue during repair. This apparent 
penetration was insisted upon very strongly by Voillemier in support of 
his theory of the mechanism of the fracture, which he supposed to be 
usually a fracture by penetration, or an impacted fracture. Dr. R. W. 
Smith, criticizing Voillemier' s theory, called attention to the outer callus, 
and, by comparing recently united specimens with those in which a longer 
time had elapsed since the injury, showed that a part at least of the 
penetration was only apparent, and was due to condensation of the 
spongy tissue in the direction of the outer shell of the upper fragment. 
But in denying penetration or impaction he seems to have overlooked 
crushing, that condensation of cancellous tissue under pressure which 
amounts to an actual loss of substance. It is undoubtedly true that in 
some cases the compact shell of the upper fragment, which may be re- 
duced to the thickness of a sheet of paper, does not penetrate the lower 
fragment while preserving its own integrity, but an equivalent result is 
eifected by the mutual crushing of both fragments along the line of frac- 
ture, and it is this which makes the angular displacement possible and 
the maintenance of reduction sometimes so difficult. 

Mr. Callender 1 made an. examination of all the specimens of this frac- 
ture, thirty-six in number, contained in the London museums, and found 

i St. Bartholomew's Hosp. Reports, vol. i., 1865, p. 281. 



FRACTURES IN THE VICINITY OF THE WRIST. 451 

the impaction not to exceed half an inch in any case, and usually much 
less ; the angle between the fragment and the shaft measured on the 
posterior surface he found to average 156°, the extremes being 143° 
and 166°, and the length of the fragment on the same side to average 
four-fifths of an inch. There was no displacement in the direction of 
pronation or supination, as is so common after fracture of the shaft of 
the radius, but in some the fragment was displaced to one side or the 
other. He says: "In the greater number of cases the two bones, 
[radius and ulna] have their mutual relations but little altered. I have 
met with only the following displacements :" 1. Fragment driven to the 
radial side with half an inch of shortening ; the carpus and hand are 
inclined to the radial side and the ulna appears unnaturally prominent. 
2. Dislocation of the ulna forward towards the pisiform bone. 3. Dis- 
placement of the fragment upward, outward, and backward with the 
formation of a new articular surface on the ulna by the growth of a half 
ring of bone upwards from the margin of the original articular surface. 
4. Fracture of the ulna seven-tenths of an inch above its end, the lower 
fragment inclining outward towards the displaced radius. 5. Displace- 
ment of the ulna backward upon the inner dorsal surface of the radius, 
the fragment of the latter being also displaced backward and far to the 
outer side. 

It has been both asserted and denied that there is also an angular 
displacement of the fragment about an antero-posterior axis, or upon the 
lower end of the ulna as a hinge, a displacement that carries the upper 
end of the fragment towards the ulna and raises the styloid process to a 
higher level. Prof. Gordon 1 says, that of 19 specimens examined by 
him the interosseous space was normal in 10 and only slightly diminished 
in the remaining 9. He found the greatest diminution in those in which 
the fracture was at a distance of more than an inch from the articular 
border. Elevation of the styloid process is established beyond question ; 
it is one of the most familiar clinical symptoms and is found also in speci- 
mens, but apparently it is accomplished by the crushing of the tissue on the 
outer side of the bone and the production of angular displacement towards 
that side similar to the one already described as found upon the dorsal 
aspect. As a matter of fact, the articular surface of the radius is usually 
displaced so as to look outward as well as backward. 

Among the lesions that may be associated with the principal fracture 
are : fracture of the ulna near its lower extremity, fracture of the sty- 
loid process of the ulna, rupture of the radio-ulnar and inter-articular 
ligaments, and perforation of the skin by the ulna. The first is not very 
common, and all the others are the consequences of momentary prolonga- 
tion of the action or variation in the degree of the force which has caused 
the fracture. Nelaton thought fracture of the styloid process of the 
ulna occurred frequently, an opinion which Dr. Hamilton says is sup- 
ported by the observations of no other writer, but quite recently Came- 
ron (vide supra) has stated that this fracture existed in five specimens 
examined by him. Dr. Moore 2 has also found it in four or five cases, 

1 Fractures of the Lower End of the Radius. London, 1875. 

2 New York Medical Record, 1870, vol. v. p. 49, and vol. xvii. 1880, p. 305. 



452 FRACTURES OF THE BOXES OF THE FOREARM. 

together with laceration of the inter-articular fibro-cartilage and dis- 
placement of the end of the ulna through the internal lateral ligament. 
He looked upon this displacement of the ulna, which he thought had not 
been before observed, as the key to the deformity and the cause of the 
difficulty of reduction so frequently met with, and believed that it existed 
in more than half the cases. A case almost identical in its pathology 
with the one that was the basis of Dr. Moore's first paper is published 
in the Bulletins de la Societe Anatomique, 1839, vol. xiv. p. 190, and 
cases of compound dislocation of the ulna in connection with fracture of 
the radius are not very infrequent, Sir Astley Cooper's book alone con- 
taining four. Concerning the condition of the fibro-cartilage I can find 
but little that is positive, since the only sources of information are the 
autopsies of recent fractures. Neither Callender nor Cameron mentions 
its condition in the specimens of recent fracture dissected by them, 
although the former says of one in which there was only a slight amount 
of displacement, that " the periosteum was torn from the bone and the 
pronator quadratus muscle was lacerated and bruised," and of another, in 
which there was impaction on the dorsal and outer aspect to the distance 
of four-tenths of an inch, that " all the muscles and tendons around the 
seat of the bone-hurt [the fracture was seven-tenths of an inch above the 
articular border] were bruised and torn, especially the pronator quadra- 
tus, which was wrenched away with the periosteum from the bone, the 
latter, immediately below and for about two inches above the line of 
fracture, being completely denuded." He adds, " the wrist joint was 
uninjured," and the inference seems fair that the ligament was not torn. 

It will be remembered that the cartilage is attached to the base of the 
styloid process of the ulna and that consequently the rupture of the 
ligament and the fracture of the process are the interchangeable conse- 
quences of the same force, traction upon the ligament through its attach- 
ment to the radius. Consequently, when the lower fragment is displaced 
upward the cartilage is put upon the stretch ; if the displacement is in- 
creased the ligament or the process gives way, and as the carpus follows 
the fragment the internal lateral ligament, already weakened perhaps 
by the fracture of the process, yields and is drawn towards the outer 
(radial) side of the ulna ; if the displacement is carried still further the 
ulna perforates the skin. 

Experiments made by Sir Astley Cooper in 1833, showed "that it re- 
quires a much less degree of force to fracture the radius than to displace 
the extremity of the ulna, or to rupture any of its connecting ligaments," 
and Dr. Moore's experiments show T ed an equivalent fact, that rupture of 
the ligaments and fracture of the styloid process of the ulna took place 
only after fracture of the radius if the force (hyper-extension of the 
hand) were prolonged. These complications therefore must be con- 
sidered the exception rather than the rule, and peculiar to the severer 
cases. 

I have not met with the record of any case in which the radius pro- 
jected through the skin, except after separation of the epiphysis ; of this 
Bruns 1 collected five cases. 

1 Arcliiv fiir Klinisclie Chirurgie, vol. xxvii. p. 240. 



FRACTURES IN THE VICINITY OF THE WRIST. 453 

A complication which, so far as I know, is entirely unique, is reported 
by Cameron, dislocation of the scaphoid forward. The patient was a 
man 32 years old, who fell from a height Feb. 27, 1877, and received 
a " well-marked Colles's fracture of the right radius." The middle and 
ring fingers were strongly flexed and the slightest attempt to extend 
them caused great pain. " A small bone or fragment of bone was felt 
lying under the skin in the middle line of the front part of the forearm, 
about an inch above the flexure of the wrist." Cameron cat it out with 
antiseptic precautions, and it proved to be the entire scaphoid bone. 
The patient made a good recovery and had a useful hand. 

Dr. Rhea Barton, 1 of Philadelphia, described clinically a fracture 
which he said was very common, and which he supposed to be the de- 
tachment of the posterior border of the articular surface of the radius. 
It does not appear from his paper that he had ever had an opportunity 
to verify the diagnosis by examination. A few specimens of such a 
fracture, most of them, I believe, found in the dissecting-room and with- 
out history, are in existence, and the injury is known in America as 
Barton's fracture. Dr. Agnew (loc. cit., vol. i. p. 905) figures a speci- 
men in which the fragment is much larger. It is perhaps hardly worth 
w T hile to try now to change this name, but there are three good reasons 
why the injury should not be known as Barton's fracture : 1st, as Dr. 
Hamilton has said, and as a reference to the original article shows, the 
injury which Barton described clinically was not what he supposed it to 
be anatomically, but was the ordinary Colles's fracture ; 2d, the lesion, 
as he supposed it to be, had been observed some years before his paper 
was published, and the specimen was presented by Lenoir to one of the 
Paris societies ; 2 and, 3d, it deserves to be classed not as a variety of 
fracture, but as a complication of dislocation of the carpus backward. 
In Lenoir's case, which is described as a dislocation by Voillemier and 
Malgaigne,a narrow fragment of the posterior articular border had been 
broken off, remained attached to the capsule, and was displaced back- 
ward with the bones of the wrist. 

An analogous case, dislocation of the carpus forward with detachment 
of the anterior border of the articular end of the radius and fracture of 
the styloid process, was reported, with the specimen, to the Socie 6 Ana- 
tomique, 3 by Letenneur. The patient was brought to the Hotel Dieu 
May 7, 1838, having received this injury and also a fracture of the 
scaphoid bone of the other wrist, by falling into a ditch while intoxi- 
cated. Mr. Callender (loc. cit., p. 291) refers to a somewhat similar 
specimen, but one in which the fragment is much larger, in the following 
words : " The line of fracture is four- tenths of an inch from the end of 
the radius on the palmar surface, but on the dorsal passed into — along 
the edge of — the articular facets." 

Other irregular fractures, too rare to be classified or systematically 
described, maybe conveniently mentioned here. 1. An oblique fracture 

1 Medical Examiner, 1838, p. 305. 

2 This fact is mentioned by Voillemier, in the Archives Grenerales de Medecine, 
1839, vol. vi. p. 402, and by Malgaigne. The Society referred to is probably the 
Societe Anatomiqne, but I have failed to find mention of the specimen in its Bulletins. 

3 Bulletins, vol. xiv. p. 102. 



454 FRACTURES OF THE BONES OF THE FOREARM 



running downward and inward and detaching the styloid process of the 
radius with more or less of the articular portion ; the larger the fragment 
the more closely will the symptoms resemble those of Colles's fracture. 

2. A condition which is the direct opposite of that constituting Colles's 
fracture ; the lower fragment is inclined toward the palmar side, and the 
crushing is also on that side. Mr. Callender (loc. cit., p. 289) reports 
such a case caused by forced flexion of the hand in a fall upon it ; there 
was a well-marked prominence on the dorsum of the forearm about three- 
fourths of an inch above the wrist-joint, and opposite it on the palmar sur- 
face was a considerable depression. The lower fragment of the radius 
was inclined at an oblique angle to the palmar surface, and projected at 
the wrist. No crepitus. Reduction could not be effected. Ten months 
later the deformity persisted, with good rotation, exaggerated flexion, 
and inability to extend the hand beyond a straight line with the forearm. 
He mentions also two specimens, one in the museum of Westminster 
Hospital, the other at St. Bartholomew's, which show the corresponding 
displacement with union. In one the styloid process of the ulna was 
broken and the lower fragment of the radius displaced forward and out- 
ward, especially in the latter direction, with penetration on the palmar 
surface to the depth of more than three-tenths of an inch. In the other 
the line of fracture is rather more than an inch above the end of the 
bone ; there is a prominent angle on the dorsal aspect in the line of the 
fracture and an elevation of new bone on the corresponding part of the 
palmar surface ; the triangular fibro-cartilage was almost completely 
separated from the radius. 

R. W. Smith (loc. cit., p. 162) describes and figures a similar case, 
in which aUo the fracture was caused by a fall upon the back of the 
hand, and Dr. Hamilton thinks he also has seen one. 

Still another instance, of very exceptional character in its mode of 
production, but apparently about the same anatomically, is quoted by 
Callender as a "green-stick" fracture. Wm. G., 
aged 14, went to the Polytechnic and was there 
galvanized ; the shocks were violent and he strug- 
gled to let go, but for a time was unable to do so. 
His wrists became painful, and the next morning he 
was unable to work. A week later he came to the 
hospital. " Either radius close to the carpal end 
was bent at a considerable angle to the shaft, so 
that, on the dorsum, there was on either forearm a 
well-marked prominence, greater on the right. All 
his other bones were natural." He remained under 
the care of Mr. Stanley for some time, and by de- 
crees recovered good motion at the wrists but re- 
tained an unsightly deformity. It was thought that 
the bones had been partly broken or bent above the 
epiphysis during the violent muscular efforts. 

3. Longitudinal fracture or fissure of the end of 
the bone (fig. 251). Dr. Bigelow 1 reported one case 



Fig. 251. 




Fissured fracture. 



1 Boston Med. and Surg. Journal, 1858, vol. lviii. p. 99. 



FRACTURES IN" THE VICINITY OF THE WRTST. 455 

and referred to a second. There was a star-shaped crack on the articular 
surface without displacement, and slight corresponding cracks in the 
shaft for more than an inch above. At first there was only lameness at 
the wrist, but after several days there were swelling and tenderness, the 
persistence of which led Dr. Bigelow to make the diagnosis. He had 
had a similar case two years before, with the same symptoms, but less 
extensive injury to the bone. 

The cause of Colles's fracture is usually a fall upon the palm of the 
hand, and in the great majority of cases the fall is only to the ground 
while walking. This is true of almost all cases in which the patients 
are somewhat advanced in life ; in the younger ones the violence is 
usually greater, as a fall from a ladder or tree. The only instance of 
fracture by muscular action is the one mentioned just above. 

The mechanism by which the fracture is produced has been almost 
from the very beginning and still is the subject of much discussion. 
Three theories have been advanced : 1st. Fracture by penetration or 
crushing ; the cancellous tissue is crushed or comminuted between the 
carpus and the diaphysis. 2d. Fracture as in other bones by decom- 
position of the force and yielding at the weakest point. 3d. Fracture 
by cross-strain exerted through the anterior ligament in exaggerated and 
forced dorsal flexion (hyper-extension) of the hand. Each is partly, none 
exclusively, true. 

There are two principal varieties of the first : one in which the lower 
fragment is comminuted, and one in which there is deep reciprocal pene- 
tration of the two fragments with but little transverse displacement. 
The former is the more common, and an exceptional degree of force is 
not required to produce it, a fall upon the palm of the hand while walk- 
ing is sufficient in an old person. The latter is probably rare, but it has 
been demonstrated by autopsy. 

The second theory is, in my judgment, true of the great majority of 
cases, and it can be best proved negatively, by disproving the third 
theory. According to it the force is received, in a fall, upon the palm 
of the hand close by the wrist, at a point which is in the direction of the 
long axis of the radius, and is, therefore, transmitted directly through 
the carpus to the articular surface of that bone. The radius is not 
straight, and, furthermore, the direction of the force may be inclined 
more or less to the axis of the bone ; the force is decomposed in the 
usual manner and the fracturing strain is exerted by one of its compo- 
nents. The bone breaks at its lower end, because that is the part least 
fitted to withstand the strain. The momentary continuation of the force 
either displaces the lower fragment backward or crushes its posterior 
portion with* or without impaction or comminution. The fracture can be 
produced upon the cadaver by placing the palm of the hand upon the 
table, holding the radius upright, and striking a heavy blow upon its 
upper end. 

According to the third theory a cross-strain is exerted upon the end 
of the bone through the anterior ligament of the wrist ; the force is 
thought to be received upon the palm of the hand at a point that lies 
posterior to the posterior border of the end of the radius, the hand is 
bent back, the ligament is put upon the stretch, and the bone is. broken 



456 



FRACTURES OF THE BONES OF THE FOREARM. 



by avulsion. The theory seems to have originated in experiments upon 
the cadaver. The earliest recorded experiments in this direction were 
those already alluded to which were made by Sir Astley Cooper in 1833, 
but not published until several years afterwards, the earliest publication 
appears to have been by Bouchet 1 in 1834. The experiment is a simple 
one ; it is sufficient to interlock the fingers with those of the cadaver and 
force the hand backward. Usually a transverse fracture is produced 
within half an inch of the articular surface of the radius, but sometimes 
the anterior ligament yields. If the action is continued after the frac- 
ture has taken place, the inter-articular ligament and the styloid process 
of the ulna are the next to yield. There is no doubt, therefore, that 
the fracture can be produced in this way, and there are a few clinical 
cases in which this was unquestionably the mode of production. But, 
with the exception of these few cases, in which the mode of action of the 
violence was distinctly exceptional, there is nothing but the dead-house 
experiments to support the theory. 

In the first place, there is good reason to think (the point is not open 
to absolute proof) that the violence in a fall is not usually received at a 
point on the palm of the hand posterior to the line of the radius ; it is 
received at the base of the thumb, at a point corresponding to the trape- 
zium. When the hand is bent backward the motion takes place between 
the first and second rows of the carpus ; the first row remains in place 
and the second row swings around until it comes almost into contact with 
the radius, as shown in figure 252. This figure represents a section 

Fig. 252. 




SectioQ in the long axis of the radius ; the hand in dorsal flexion. Tr-m, trapezium : 
Tr-d, trapezoid. 

made through the radius and the second metacarpal bone and traversing 
the point upon the palm which receives the blow in a fall, and as the 
position is that of extreme physiological dorsal flexion it is evident from 
it that no cross-strain can be exerted until after this limit has been passed 



1 These sur les Luxations du Poignet. Quoted by Malgaigne. 



FRACTURES IX THE VICINITY OF THE WRIST. 457 

and the second row of carpal bones have obtained a bearing upon the radius. 
Before this can take place the flexor muscles must be overpowered, and 
that is a fact which I think has not been taken properly into account in 
reasoning from the results of experiments. The strain does not come 
upon the ligament unless the hand is caught under the body in the fall 
and bent far back. Ordinarily the hand is not bent back even to a 
right angle, not even far enough to make the anterior ligament of the 
wrist tense, much less to exert a fracturing strain through it. Moreover 
the resemblance between the fractures produced experimentally by over- 
extension and those caused by falls during life is by no means so close as 
has been asserted. 

Finally, there are cases on record in which it appears to be proved 
that a fall upon the back of the hand produced the characteristic fracture 
and di5placement of the lower fragment backward. In a case observed 
by Prof. Cameron (loc. cit., p. 97) the patient, an elderly woman, fell 
" upon the back of her wrist, the fist being kept shut in order to retain 
a grasp of some small object held in the hand." The most reasonable 
explanation of this identity of result in opposite positions of the hand 
appears to me to be obtained by rejecting the theory of cross-strain and 
accepting the second one. 

Muscular contraction, which was thought by Pouteau to be the sole 
cause of the fracture, and has since been invoked by others, is now looked 
upon only as an adjunct of uncertain importance. The only recorded 
case in which it appears to have been the sole efficient cause is the one 
already mentioned of the boy in whom the fracture followed the mus- 
cular contraction excited by a strong galvanic current. The mechanism 
in this case appears to have been fracture by exaggerated palmar flex- 
ion, and, considering the unusual circumstances of this case and the 
weakness of the extensor muscles as compared with the flexors, there is 
not the slightest reason to think that the ordinary fracture can be due to 
preponderant action of the extensors. The combined action of both sets 
of muscles in the spasmodic effort to arrest a fall unquestionably supple- 
ments that of the violence received upon the palm, and their tonic con- 
tractility tends to keep up the displacement when there has been loss of 
substance by crushing of the bone ; but in an uncomplicated transverse 
fracture without crushing the tendency to reproduction of the deformity 
by the action of the muscles after its reduction is slight, or even absent. 1 

The symptoms are marked and characteristic, but crepitus and abnor- 

' Lack of space prevents detailed reference to, and discussion of, the views and 
arguments advanced by others upon this question of the mechanismof Colles's fracture. 
The literature of the subject is voluminous. The reader is referred, in addition to 
the works already quoted, especially to papers and discussions by Drs. Hamilton, 
Pilcher, Levis, and others in the N. Y. Medical Record, 1878 to 1881. passim, the 
Philadelphia Medical Times, 1881, and the Annals of Anatomy and Surgery, March, 
1881, to a monograph by Prof. Gordon of Belfast (Fractures of the Lower End of the 
Radius, London, 1875)> an d to a thesis by Schmit (Des Fractures de l'Extremite in- 
ferieur du Radius, Paris, 1878). Drs. Pilcher, Gordon, and Schmit are advocates of 
the theory of fracture by cross-strain or avulsion. Dr. Pilcher has in addition called 
especial attention to the periosteal bridge upon the dorsal surface, to the part taken 
by the "oblique anterior carpo-ulnar fasciculus" in controlling the direction and 
extent of the displacement, and to the " wedge-action " of the carpal bones in caus 
ing comminution. 



458 



FRACTURES OF THE BONES OF THE FOREARM. 



mal mobility, so common in other fractures, are rarely present in this. 
The most striking part of the deformity is a deviation backward at the 
wrist of the long axis of the forearm, so that when viewed from the 
radial side its appearance is like that represented in fig. 253, and was 



Fig. 253. 




Deformity in Colles's fractur 



aptly compared by Yelpeau to the outline of a silver fork, a comparison 
which has survived in the name " silver fork fracture," by which it is 
frequently known. The cause of this change in the outline, so far as it 
is due to the position of the fragments, is shown in fig. 254. The dis- 



254. 




Colles's fracture. Union with persistence of displacement. (Smith.) 



placed carpal fragment forms the prominence on the dorsum, and the 
lower end of the upper fragment is marked by the prominence on the 
anterior aspect. If the outer portion of the lower fragment is dis- 
placed upward to a much greater extent than the inner portion, the hand 
is noticeably deflected to the radial side, and the lower end of the ulna 
is prominent. 

If the surgeon marks the positions of the styloid processes by press- 
ing the end of a finger into the side of the joint below and against the 
end of each, he will see that that of the radius has risen, so that instead 
of being about a quarter of an inch lower (nearer the hand) than that 
of the ulna, as it usually is, it has risen to the same level, or even 
above it. 

If now the wrist is flexed and pressure is made upon the dorsum of 
the forearm just above the prominence, the tendons of the radial exten- 
sor muscles can be felt as a sort of cord stretching across from the upper 
to the displaced lower fragment ; this sign was pointed out by Velpeau, 
but it is lacking if the lower fragment is not displaced bodily backward. 

The swelling upon the anterior surface of the forearm is quite marked, 
and is sharply rounded off towards the wrist where it adjoins the depres- 



FRACTURES IN/ THE VICINITY OF THE WRIST. 459 

sion corresponding to the dorsal prominence. It is produced in part by 

the prominence of the lower end of the upper fragment, which results 

from the displacement of the lower fragment and the carpus, and in part 

by an eifusion within the sheaths of the tendons, which is prevented by 

the annular ligament from showing itself nearer the wrist. The presence 

of this effusion can be readily demonstrated by placing the fingers of 

one hand upon the patient's palm and pressing with those of the other 

upon the prominence in the forearm ; the wave can be felt to pass from 

one to the other. 

Crepitus and abnormal mobility may sometimes be obtained by the 

manoeuvre recommended by Colles : " Let the surgeon apply the fingers 

of one hand to the seat of the suspected fracture, and, locking the other 

hand in that of the patient, make a moderate extension until he observes 

the limb restored to its natural form ; so soon as this is effected let him 

move the patient's hand backward and forward, and he will at every 

such attempt be sensible of a yielding of the fractured end of the bone." 

In communicating these movements to the hand, it is well to grasp the 

lower fragment between the thumb and fingers to insure and recognize 

. . . ■ 

its movement with the hand. In some cases the reduction is permanent, 

in others the deformity returns as soon as the extension ceases. 

Pressure below the ulna on the inner side of the wrist is painful, also 
along the line of fracture on the dorsum of the radius. The hand is 
held in the semi-prone position, and rotation is painful. 

The diagnosis is made by recognition of the above signs and symp- 
toms. In difficult cases, fat people and children without displacement, 
it may be made upon the existence of a well-defined transverse line of 
tenderness on pressure on the dorsum of the radius, deepening of the 
transverse folds on the palmar aspect of the wrist, loss of power in the 
limb, and history of the case. 

A sprain or contusion may be mistaken for a fracture if the limb has 
been broken previously and has united with deformity, for it will pre- 
sent many of the physical and functional signs. The question therefore 
should always be asked whether the wrist has suffered a previous iniunr. 

Course and Prognosis. — Firm union between the -fragments may be 
expected in a month, and failure of union, according to Dr. Hamilton, is 
unknown. The course is uneventful, except for the inflammatory symp- 
toms of the first week ; these may be severe, and if the bandages are 
not properly looked after strangulation and sloughing may follow. The 
prognosis with reference to deformity depends, of course, upon the com- 
pleteness of the reduction and retention. As a rule, permanent deform- 
ity after fracture in youth is slight or entirely absent ; but in old people 
the case is different, either because the original displacement is greater, 
or because crushing and comminution make complete reduction and 
retention practically impossible. 

The prognosis with reference to function is somewhat better, since the 
persistence of even marked displacement does not necessarily entail dis- 
ability. The range of motion at the wrist may be somewhat restricted, 
and yet may be wide enough to answer all purposes, and a change in the 
direction of the articular surface is still compatible with free and pain- 
less motion. Rigidity of the wrist and fingers usually persists for some 



460 FRACTURES OF THE BONES OF THE FOREARM. 

weeks, or even months, and in exceptional cases, in the old and rheuma- 
tic and in those where there has been much inflammation of the sheaths 
of the tendons and of the wrist-joint, it may persist for years. I have 
seen two cases in which the hand was practically useless a year or two 
after the receipt of the injury. There was much deformity in one of 
them. This rigidity of the fingers is due in part to their prolonged im- 
mobilization and in part to inflammation within the sheaths of their 
tendons in the forearm. 

The possible arrest of the growth of the bone after separation of the 
epiphysis deserves mention, although it is an exceptional consequence of 
the injury. It has an especial importance at this point because of the 
presence of two parallel bones ; if the growth of the lower end of the 
radius is arrested while that of the ulna continues, a noticeable deviation 
of the hand towards the radial side must result. 

Treatment. — Complete reduction of the displacement is, of course, 
essential to prevent permanent deformity. The ease with which it can 
be accomplished varies greatly in different cases. The method quoted 
above from Colles is sometimes sufficient, traction upon the hand with 
some direct pressure upon the fragments ; in other cases forcible pressure 
must be made upon the fragments, the forearm is grasped with the 
fingers upon the palmar prominence and the thumbs upon the dorsal one, 
and the pieces are pressed into line. Dr. Pilcher thinks the untorn 
periosteum of the dorsal side is a potent obstacle in many cases to re- 
duction by direct pressure, because it holds the lower fragment tilted 
backward, and he recommends that reduction should be made by first 
bending the wrist backward so as to relax this band of periosteum, then 
making slight traction upon it in the line of the forearm, and finally 
moderate pressure upon the dorsum of the lower fragment as the hand 
is straightened. 

Splints in great variety have been devised with the view to avoid the 
characteristic deformity which is found so frequently to have taken place 
or to have persisted during treatment. The theory upon which many of 
them have been constructed is that the essence of the deformity lies in 
the shortening of the outer side of the radius, in the ascent of its styloid 
process, and that this can be met by extreme adduction of the hand; for 
a similar reason flexion of the wrist is also recommended. The first 
embodiment of this principle was in Dupuytren's ulnar splint, a metal 
rod made fast to the inner side of the forearm and curving away from 
the hand so that the latter could be drawn towards that side by tapes 
carried around it under the thumb and made fast to buttons on the splint. 
The idea survives in the "pistol-shaped" splints, in all, in fact, in which 
the portion of an anterior or posterior splint which corresponds to the 
hand is deflected towards the ulnar side. The idea is one which is sug- 
gested very naturally by the deformity, the error lies in the inference 
that effective traction can be made through the loose ligaments of the 
joint. There is no difficulty in modifying the position of either condyle 
of the humerus or femur by bending the forearm or leg to the opposite 
side if the lateral ligaments remain untorn, because the bond is close and 
firm and allows no lateral motion, but at the wrist the case is very differ- 
ent, the ligaments are loose and there is free motion of the joint in every 



FRACTURES IN THE VICINITY OF THE WRIST. 461 

direction. The ligament is not put upon the stretch until the limit of 
the range of motion is reached and the opposing muscles are drawn out 
to their full length. Although theoretically the ligament should then be 
efficient to prevent the ascent of the fragment if the lateral motion of 
the wrist were that of a hinge joint, yet, as Drs. Hamilton and Cameron 
have pointed out, this is not so in fact ; there is no fixed point of support 
upon the ulnar side to make the strain effective, and the result is quite as 
much to force the wrist and the end of the radius outward away from 
the ulna, as to draw the fragment down. Those who favor an extreme 
angular position of the hand do not attach sufficient importance I think 
to the fact that the opposing muscles are thus put upon the stretch, and 
that when the hand is fixed in its position their contractility is exerted 
upon the lower fragment of the radius exactly as if their tendons were 
attached to it, and as this contractility is increased by their extension its 
tendency to displace the fragment directly upward is increased in like 
manner and cannot be efficiently opposed if there has been loss of sub- 
stance by crushing or if the fracture is oblique backward and upward. 
The rule w T hich is good elsewhere is equally good here, the muscles 
should be relaxed. 

If the line of fracture is transverse and there is no crushing not much 
is needed to keep the fragment in place after it has once been properly 
reduced; and if, on the other hand, there is much loss of substance by 
crushing or comminution or if the line of fracture is oblique the artificial 
outside support which is then needed to prevent displacement cannot be 
given, because the fragment is too small to be effectively acted upon by 
a splint. 

The indications are of two kinds : to immobilize the fragments, and to 
allow passive and voluntary movements of the fingers in order to prevent 
or diminish their subsequent stiffness. The tendency is towards dis- 
placement of the lower fragment backward, and the splints need there- 
fore to be so adapted as to make pressure in the antero-posterior direc- 
tion. One of the earliest devices is one that is now in general use ; 
anterior and posterior splints so padded that the former presses upon the 
upper fragment and the latter upon the low r er one. The details may vary 
within certain limits, but a convenient form is as follows : — 

Two splints are made of light wood of a uniform breadth equal to the 
largest diameter of the forearm ; the anterior one should be long enough 
to extend nearly from the bend of the elbow to the raetacarpo-phalan- 
geal joints, the other from the corresponding height to the back of the 
carpo-metacarpal joint. These should be padded w r ith cotton, wool, or 
hair as described in the Chapter on Treatment, the padding being espe- 
cially thick on the anterior (palmar) splint at the part which corre- 
sponds to the lower inch of the upper fragment and on the lower end of 
the posterior splint so as to make pressure on the lower fragment. These 
splints are placed directly against the skin and secured by two strips of 
adhesive plaster, one at either end. Care must be taken to have the 
anterior splint short enough to let the fingers bend over its end easily 
and not to make annoying pressure at the elbow. The posterior splint 
must not encroach upon the back of the hand (fig. 255). 

The addition of a roll of bandage an inch and a half in diameter 



4(32 



FRACTURES OF THE BONES OF THE FOREARM. 



secured to the lower end of the anterior splint by stitching or adhesive 
plaster in an oblique direction so that its long axis is inclined upward 



Fig. 255. 




^L_J 



Diagram to show relative positions of the splints. (The splints and pads should be placed an inch 
nearer the elbow than is shown in the figure.) 

and to the ulnar side increases the comfort of the patient by supplying a 
convenient support for the flexed fingers and thumb (fig 256). The 

Fig. 25G. 




Anterior splint for Colles's fracture. 



same support for the hand and fingers is obtained in some other splints 
by modelling them suitably in wood or by padding. The roller fur- 



Fte. 257. 




Levis's splint for Colles's fracture. 



Irishes a convenient means of extemporizing the splint and is associated 
in' this coantry with the name of the late Dr. Hays, of Philadelphia. 



FRACTURES IN THE VICINITY OF- THE WRIST. 463 

Dr. Hamilton inclines the lower end of the anterior splint towards the 
ulnar side so that the hand is kept adducted. He does this not with the 
idea of thereby exerting any traction upon the lower fragment but 
merely to keep the radius more completely in view in order to recognize 
more readily the condition and situation of the compresses and pads. 
Dr. Levis of Philadelphia has devised a convenient splint of tin moulded 
to fit the irregularities of the palm, and curved to match the anterior 
curvature of the radius (fi^. 257). 

Gordon's splint (fig. 258), a much more elaborate one, some of the 
features of which are based upon arguments that I do not understand, 

Fig. 25S. 




Gordon's splint for Colles's fracture. 

is apparently in general use in Ireland and is said by Mr. Bryant to 
have found favor. A detailed description is unnecessary since the 
splint must be obtained from an instrument maker. 

The forearm must be supported in a sling, and the patient should be 
instructed to move the fingers frequently. 

Some surgeons, depending upon the slight tendency to recurrence of 
the deformity after complete reduction, discard splints entirely in the 
hope of thereby diminishing the subsequent rigidity of the fingers, a 
practice of doubtful propriety, I think, unless the patient is confined to 
the bed with the forearm and hand immobilized upon suitably adjusted 
pillows. I have seen several fractures treated successfully in this latter 
w T ay in Gosselin's service at La Charite. Dr. Moore who, as has been 
said, considers dislocation of the ulna the common and most important 
part of the lesion, dresses with a small cylindrical pad about two inches 
long secured against the anterior face of the ulna by a strip of adhesive 
plaster wrapped very tightly about it and the lower end of the radius. 

All are agreed concerning the value of complete reduction, which 
should be made if necessary with the aid of anesthesia. This once 
thoroughly accomplished makes subsequent treatment, except immo- 
bilization of the limb, in many cases comparatively unimportant. The 
bandages should not be tightly applied at first, they must be frequently 
inspected during the first day or two and loosened if necessary. If the 



464 FRACTUBES OF THE BONES OF THE FOREARM. 

reaction is severe the patient should be put to bed, the arm placed on a 
pillow, and local treatment used to combat the inflammation. 

Finally, it must be remembered that it is often impossible, on account 
of the crushing, comminution, or impaction, to reduce the displacement 
completely or to maintain the redaction, and that in such cases perma- 
nent deformity of the parts is inevitable. 

The question sometimes arises whether deformity, persisting for some 
time after the injury and the result of an error in diagnosis or of failure 
of treatment, can be corrected. Among Dupuytren's earliest cases 
were three of this kind, and he succeeded in overcoming the deformity 
by steady forcible traction and pressure upon the fragments on the 
20th, 29th, and 80th days after the receipt of the injury, the patients 
being respectively 69, 10, and 13 years old. Dr. J. L. Little 1 has 
recently treated a case successfully by refracture six weeks after the 
original injury. The patient was a woman 30 years old, and there were 
much deformity and pain. 

2. Fractures at the Wrist other than Colles's. — Some fractures 
of the wrist which, while not entitled to classification with Colles's frac- 
ture, yet bear a certain resemblance to it, have been already described 
with such details as are needed. 

Fracture of the Styloid Process of the Radius alone is rare. Dr. 
Hamilton quotes a case treated by Dr. Jas. C. Hutchison in which the 
fracture was caused in a boy 14 years old by a fall from a height of 
thirty feet. There was a second fracture at the junction of the lower 
and middle thirds. The fracture of the styloid process broke off a frag- 
ment that included about one-fifth of the articular surface, and this 
fragment was drawn up on the posterior surface to a distance of one and 
a half inches by the supinator longus. The position of the hand was 
the same as in Colles's fracture. An attempt to draw the fragment into 
place by means of a compress and adhesive plaster was unsuccessful ; 
the fragment united in its new position but the movements of the wrist 
were not impaired and the power of rotation soon returned. 

Dr. Hamilton was consulted in another case four months after the 
fracture had taken place. The fragment was tilted forward and carried 
slightly upward by the action of the supinator longus and was movable. 
The form of the wrist was natural and its movements unimpaired. 

Dr. Agnew speaks of a combination of Colles } s fracture with fracture 
of the posterior articular border and says there is a fine specimen of it 
in the collection of Prof. John Neill. 

Of transverse fracture of the radius just above its carpal surface with 
displacement of the fragment forward, which has already been spoken 
of as sometimes produced by a fall upon the back of the hand, it needs 
only to be said that the diagnosis is made by attention to the position 
of the styloid process with reference to the carpus and the ulna and by 
recognition of the line of limited tenderness if mobility and crepitation 
cannot be obtained. The treatment should be the same as in Colles's 

1 N. Y. Med. Record, March 4, 1882, p. 245. 



FRACTURES IN THE VICINITY OF THE WRIST. 4b5 

fracture, except that the position of the pads should be changed to meet 
the different displacements. 

Fracture of the styloid process of the ulna, a frequent accompani- 
ment of Colles's fracture, is sometimes observed separately as the result 
of direct violence. In addition to the usual symptoms of pain and 
swelling, mobility of the process could probably be recognized by direct 
manipulation or by abduction of the hand. Dr. Agnew says some de- 
formity is likely to remain, and that in the only case he has seen the 
union was fibrous. He advises treatment upon an anterior splint with 
the hand inclined towards the ulnar side and in dorsal flexion so as to 
relax the extensor carpi ulnaris. 

Fracture of both bones near the wrist is occasionally seen, and is said 
to resemble dislocation of the wrist backward. The diagnosis is made 
by attention to the relations between the styloid processes and the 
carpus and hand. Treatment as in Colles's fraccure. 

In compound fractures, which are usually by direct violence, every 
eifort should be made to avoid amputation. Good results have been 
obtained by excision of the lower end of the ulna alone and of both 
bones. 



30 



466 FRACTURES OF THE CARPUS AND HAND 



CHAPTER XXIII. 

fractures of the carpus and hand. 

1. Fractures of the Carpus. 

Simple fractures of the carpal bones appear to be very rare. Only 
a few cases have been reported in which the nature of the injury was 
shown by direct examination, and I have met with only one in which the 
diagnosis was made during life. As the symptoms are very obscure it 
is possible that the injury may be more common than is supposed, and 
may frequently pass unrecognized. The number, size, and relations of 
the bones are such that they can be broken only by direct violence, as 
a blow, the passage of a wheel, or a fall upon the hand, or by traction 
(avulsion) in forced dorsal flexion or displacement. It occasionally 
happens in experimental fracture of the lower end of the radius that 
some one of the carpal bones is broken, and the same complication has 
been observed clinically. In a case of fracture of the lower end of the 
radius observed by Dr. Wm. Hunt, 1 of Philadelphia, the semilunar 
bone was broken transversely, one part being displaced backward with 
the carpus and the fragment of the radius, the other remaining attached 
to the unbroken anterior border of the radius by the anterior ligament. 

Berard 2 refers to two cases observed by Cloquet, in which fractures 
of the carpus were caused by a fall upon the hand from a height ; both 
remained unrecognized until after the death of the patients from other 
injuries received at the same time. Malgaigne quotes from Jarjavay a 
fracture of the scaphoid produced in the same way ; and another, also 
of the scaphoid and caused by a fall into a ditch, was reported by 
Letenneur. 3 

In a case quoted by Polaillon, 4 the diagnosis w T as made during life. 
The patient, a young and vigorous workman, fell from the second story 
of a house, and struck upon his feet and right hand. Robert examined 
him and could find no signs of fracture of the radius or ulna, but by 
grasping the styloid processes firmly with the fingers of one hand and 
the wrist with the other, and moving the latter backward and forward 
he felt a crepitus which was not transmitted to the radius and ulna. 

The only symptom which could make the diagnosis possible is crepita- 
tion, and it might be very difficult to determine whether this had its 
origin in the carpus or in one of the adjoining bones. 

1 Annals of An at. and Surg., March, 1881, p. 110. 

2 Diet, en 30 Vols., art. Main, p. 524. 

3 Bull, de la Societe Anatomique, vol. xiv. p. 162. 

4 Diet. Encyclopedique, art. Main, p. 50. 



FRACTURES OF THE METACARPAL BONES. 467 

The treatment would consist in immobilization of the wrist for two or 
three weeks, and it is probable that partial ankylosis would result. 

2. Fractures of the Metacarpal Bones. 

While simple fracture of a metacarpal bone is not a very common 
accident, still it is not so rare as some authors have inferred from hospi- 
tal statistics. Malgaigne found 16 cases in a total of 2377 fractures of 
all kinds treated at the Hotel Dieu, a percentage of 0.67 ; Polaillon 64 
cases in a total of 5517 fractures treated in the Paris hospitals during 
the years 1861-2-3, a percentage of 1.16, while the combined tables of 
hospital and dispensary practice in Chapter 1. give 104 cases in a total 
of 4310 fractures, a percentage of 2.41. Of Polaillon's 64 cases, 57 
were men, only two were old, and none were infants. 

The same author tabulated 102 cases according to the bone affected, 
with the following result : — 

1st metacarpal, 8 fractures. 

2d " 16 

3d " 34 

4th " 35 " 

5th " 9 " 

In 14 cases two bones were broken, and in 3 cases three bones. 
There appears to be no notable difference in the frequency with which 
different portions of the bone are broken. A very few cases of pro- 
bable separation of the distal epiphysis have been recorded, one by 
Malgaigne, one by Hamilton, and one quoted by Polaillon from a thesis 
by Pichon, the ages being 9, 8, and 12 years respectively. There was 
failure of union in Malgaigne's case, but without disturbance of func- 
tion when last seen, thirteen years after the injury. Experiments upon 
the cadaver have shown that the principal varieties of fracture common 
to long bones can be produced in the metacarpus, and that those due to 
direct violence are usually toothed and transverse, those due to indirect 
violence more frequently oblique than transverse. The usual displace- 
ment is angular, the head of the bone being drawn forward towards the 
palm, and the apex of the angle being directed backward, and at the 
same time the fragments may override longitudinally notwithstanding 
the attachments which bind them to the adjoining bones. 

The cause may be direct or indirect. When direct it is a blow upon 
the back of the hand, a fall or blow upon its side, or a crushing force, 
the hand being caught between two solid bodies. The first, second, and 
fifth metacarpals are the ones most frequently broken by direct violence. 
A very exceptional variety is one mentioned by Sanson, 1 and quoted by 
most subsequent writers. He says he had seen several times a fracture 
caused by the reaction upon the hand of the stick with which a blow 
w T as struck. 

The commonest indirect cause is violence received upon the distal end 
of the bone in the direction of its long axis, by which its normal curve 

1 Diet, en 30 Vols., art. Main, p. 525. 



468 FRACTUEES OF THE CARPUS AND HAND. 

is exaggerated and fracture produced, as in a fall upon the knuckles or 
a blow with the fist. Lonsdale reported a case in which fracture of the 
third metacarpal was caused by a fall upon the end of the outstretched 
middle finger. In a case reported by Dupuytren, the third metacarpal 
bone was broken by being bent backward in a trial of strength, the con- 
testants trying to force each other's wrist back, their fingers interlocked 
and the ends pressing upon the back of the other's hand. Yelpeau saw 
the same bone broken by traction upon the index and middle fingers 
with some twisting. 

The symptoms are the deformity due to the displacement of the distal 
fragment, abnormal mobility, crepitation, pain, and inability to move the 
fingers. The deformity consists usually in a projection upon the back 
of the hand at the seat of fracture and in the prominence of the head of 
the bone upon the palm, and sometimes in shortening, which, although 
slight, can be easily recognized by comparison with the corresponding 
finger of the other hand. Abnormal mobility and crepitation may be 
found by flexing and extending the corresponding finger and at the same 
time making pressure upon the palm at the supposed seat of fracture, so 
as to make the fragments prominent behind. The peculiarity of the 
pain is that it can be suddenly and sharply increased by pressing the 
finger towards tjie carpus ; this was pointed out by Verneuil and is 
insisted upon by him as almost pathognomonic. 

The course of the fracture is usually simple, and ends in consolidation 
in the course of three or four weeks. The complications which occurred 
in the eighty-one cases collected by Polaillon were inflammation of the 
carpo-metacarpal joint in one, union with marked displacement, fusion 
of adjoining bones when both were broken in one, deviation of the 
extensor tendons by a voluminous callus in one, and failure of union in 
three. In a case reported by Dr. Hamilton, fracture of the second 
metacarpal, caused by striking with the fist, was followed by suppura- 
tion, complete ankylosis of the wrist, and partial ankylosis of the 
fingers. 

Treatment. — The first indication is to prevent a too severe inflam- 
matory reaction if it threatens, and with this object the hand must be 
kept at rest in an elevated position and treated with hot fomentations or 
cold, according to the peculiarities of the case or the preferences of the 
surgeon. 

If there is no displacement or tendency thereto, a simple immobilizing 
dressing of cotton, bound on snugly with a roller bandage, is sufficient, 
the fingers being left free to prevent their stiffening. 

A very ancient method, one that has always found favor, is to fill the 
palm with a mass of tightly packed cotton, or some similar substance, or 
a ball over which the fingers are closed and fastened down with a band- 
age or adhesive plaster. The flexion of the finger over the firm mass 
tends to draw the knuckle downward, and thus prevent shortening. 
The support furnished by the adjoining bones is an additional aid 
against displacement, and the back of the hand can be left partly un- 
covered for inspection. 

In fracture of the third and fourth metacarpals the hand may be bound 
upon a dorsal or palmar longitudinal splint suitably padded and fastened 



FRACTURES OF THE PHALANGES. 469 

with a roller, but this plan is unsuited to fractures of the second or fifth, 
because the circular compression exerted by the bandage tends to cause 
lateral displacement. Malgaigne used narrower- splints, crossing the 
band transversely in front and behind at the seat of fracture, and made 
fast by binding the projecting ends together. 

If continuous extension seems necessary to overcome a tendency to 
displacement, the hand and forearm can be placed upon a long splint, 
which is made fast at the elbow for counter-extension and projects well 
beyond the fingers. An elastic cord is attached by means of adhesive 
plaster and a bandage to the finger corresponding to the broken bone, 
and fixed with suitable tension to the projecting end of the splint. 

Sabatier sought to meet the same indication by fastening the finger 
to the adjoining ones with adhesive plaster. 

Dr. Hamilton saw a case of compound fracture of the second meta- 
carpal bone about three-fourths of an inch from its carpal end, in which 
the broken end of the proximal fragment was directed backward. Dorsal 
flexion of the wrist made reduction easier, and the hand was kept in this 
position by appropriate splints during treatment. Union took place with 
some backward displacement. 

Fracture of the first metacarpal is to be treated like fracture of a 
phalanx. 

3. Fractures of the Phalanges. 

In the great majority of cases these fractures are due to direct vio- 
lence, and in consequence they are frequently compound, or at least 
accompanied by laceration or bruising of the soft parts. A few cases 
have been reported of fracture by indirect violence, as in a fall or blow 
upon the end of the finger, or by having the finger caught and fixed 
while the hand continued to move. 

The first phalanx is the one most frequently broken, the terminal 
phalanx most rarely. 

The symptoms upon which the diagnosis is made in simple fractures 
are mobility and crepitation, since the displacements are usually masked 
by the swelling. 

The progress of the case in simple fracture is towards prompt repair ; 
in compound fractures the suppuration is apt to be profuse, and necrosis 
of splinters and even of one of the principal fragments is not uncommon. 

A well-established rule of treatment in injuries of the hand is to save 
everything that can be saved, but it needs limitation in compound frac- 
tures of the fingers. While it is desirable to save the thumb or any 
part of it, even at the price of ankylosis of both the joints, the same 
value does not attach to the fingers, and a rigid deformed finger that 
has been saved with much difficulty, is often a source of so much incon- 
venience that the patient subsequently seeks relief in amputation. It is 
better that members so injured should be removed at first, for the attempt 
to save them cannot be made without incurring certain risks, prolonged 
suppuration, phlegmon of the forearm, tetanus, which, although some- 
what remote, should not be lost sight of. This statement applies with 
especial force to the little finger, because of the communication of its 



470 



FRACTURES OF THE CARPUS AND HAND. 



flexor sheath with the common one of the palm and wrist, a communica- 
tion which does not exist in the case of the other three fingers. Although 
the treatment of inflammation of the hand does not fall within the scope 
of this work, I take the opportunity to testify to the value of antiseptic 
baths, and to urge free and early incisions with thorough drainage. It 
is my practice to place the hand for an hour or an hour and a half in a 
tepid bath containing two per cent, of carbolic acid and then to envelop 
it in thick layers of cotton bound on firmly with a roller bandage. The 
bath is repeated once or twice a day or once every two days according 
to circumstances. 

In the treatment of simple fracture the usual indication to prevent dis- 
placement is habitually met by means of a moulded palmar splint made 
of pasteboard, felt, or gutta percha to which the finger, slightly flexed, 
is made fast (fig. 259). This answers very well for the terminal and 

Fig. 259. 




Hamilton's gutta percha splint for the finger. 



middle phalanges but it does not support the proximal one sufficiently. 
Sometimes a straight splint is used, sometimes a piaster of Paris band- 
age, and sometimes extension is made by means of adhesive plaster as 
mentioned above in the treatment of fracture of the metacarpal bones. 

The general impression seems to be that the displacement to be guarded 
against is an angular one with the angle directed backward and caused 
by the contraction of the flexor tendons. Mention has been made of an 
angular displacement in the opposite direction sometimes observed in the 
proximal phalanx, and it has been attributed to the pressure of the roller 
bandage which binds the finger to the splint ; the phalanx rests upon the 
splint at its two ends while its centre is not only unsupported but is 
actually pressed out of line by the bandage. I have seen this displace- 
ment under circumstances where this cause could not be alleged, even in 
a case of recent fracture by indirect violence, and I attribute it to the 
action of the interosseous muscles. The persistence of this displacement 
constitutes a serious inconvenience, for it limits flexion of the metacarpo- 
phalangeal joint and creates a prominence upon the palmar aspect of the 
phalanx the skin covering which may become so sensitive that a firm 
grasp cannot be taken of any hard object. 

A palmar splint does not prevent this displacement unless combined 
with permanent extension, and if used it must be carefully padded and 
frequently inspected. I prefer to close the hand upon some firm cylin- 
drical body, a roller bandage for example, and fasten the fingers down with 



FRACTURES OF THE PHALANGES. 471 

strips of adhesive plaster applied longitudinally along the back of the 
hand, the fingers, and the front of the forearm, and additionally secured 
with a few turns of a bandage. The roll must be large enough to give 
ample support, and by passing the finger along the dorsum of the pha- 
lanx the occurrence of displacement can be recognized. It will be remem- 
bered that the tendon of each extensor muscle is attached to the base of 
the proximal phalanx by a short band which limits the action of the muscle 
to that phalanx, and that the extension of the middle and distal phalanges 
is accomplished by the interossei, which also flex the metacarpophalan- 
geal joint and are relaxed when the fingers are closed. The tendency to 
overriding is thus effectively opposed by this position, and the displace- 
ment which most needs to be guarded against under the circumstances is 
the one also that is most readily detected, angular displacement with the 
angle directed backward. 

Dr. Hamilton reports a case of union with rotatory displacement of 
the distal segment about its long axis, an unsightly and troublesome de- 
formity that should be guarded against. 

Support that may be sufficient in some cases can be readily obtained 
by binding the broken finger to the adjoining ones and supporting both 
or all three upon a common splint. 



472 FRACTURES OF THE PELVIS. 



CHAPTER XXIV. 

FRACTURES OF THE PELVIS. 

These are among the rarest fractures, as may be seen by reference to 
the tables in Chapter I., averaging, perhaps, one in three thousand fractures 
of all kinds, although the percentage for obvious reasons is considerably 
higher in hospital practice. 

The form, size, and connections of the bones which constitute the pel- 
vis are such that their fracture can be caused, except at some of the 
more exposed and outlying points, only by extreme violence, a fact 
which taken in connection with the proximity of important viscera ac- 
counts for the recognized gravity of the injury. According to Agnew 1 
the mortality was 36 in 94 cases admitted into the Pennsylvania Hos- 
pital, and 24 in 65 cases collected by Dr. Lyon.' 

Although the pelvis is composed of several different bones, it does not 
seem desirable to describe the fractures of each separately, especially 
since multiple fractures are common, and a single fracture may involve 
more than one bone. I shall therefore group in one section all Iractures, 
single, double, or mutiple, which break the continuity of the ring of the 
pelvis, and then consider separately some fractures of the sacrum, coccyx, 
the wing of the ilium, and the ischium, which do not break the continuity 
of the ring. 

1. Fractures of the Ring of the Pelvis. 

The most frequent cause of this lesion is the passage of the wheel of 
a heavily laden wagon across the thigh and hypogastrium ; among the 
others are falls upon the feet or the buttocks, the caving in of an embank- 
ment, and crushing between the buffers of railway cars or other heavy 
moving objects. The position and the number of the fractures vary 
with the degree of the violence and the portion of the ring upon which 
it is received. When it falls upon the symphysis and is directed back- 
ward the arch yields at its weakest point, and the line of fracture passes 
through the horizontal and descending branches of the pubis, sometimes 
on one side alone, sometimes on both sides. If the force then continues 
to act it presses the sides apart, and either breaks the sacrum vertically 
(by avulsion) or ruptures the ligaments of the sacro- iliac synchondrosis, 
or breaks the ilium into the synchondrosis or into the sacro-sciatic notch ; 
and it does this also sometimes on one side alone, and sometimes on both. 
Voillemier, 2 who was the first to call attention to this combination with 
vertical fracture of the sacrum attributed it exclusively to falls upon the 

1 Loc. cit., vol. i. p. 921. 2 Clirrique Chirurgicale, 1862, p. 77. 



FRACTURES OF THE RING OF THE PELVIS. 473 

ischium, and rejected the explanation offered of the only case reported 
before his, that of Richerancl, who attributed it to a fall upon the foot. 

When the violence is received upon the side of the pelvis, or the 
great trochanter, or even upon the foot, it may cause what Malgaigne 
described as double vertical fracture of the pelvis, or fracture of the ace- 
tabulum to a variable extent, and in one case a fall upon the foot caused 
dislocation of the entire os innominatum, separating it cleanly at the 
symphysis pubis and sacro-iliac joint and forcing it upward. In Mal- 
gaigne's double vertical fracture the anterior fracture occupies the same 
position as when the force has been received upon the symphysis, it 
crosses the pubis ; the posterior one is usually entirely within the ilium 
and behind the acetabulum, but Malgaigne includes in this group Rich- 
erand's case, above alluded to, in which the posterior fracture occupied 
the sacrum, and there seems to be no good reason for separating this 
group from the main class, although the symptoms in it are made some- 
what different by the greater mobility of the segment with which the 
femur articulates. In fracture of the acetabulum, which can be caused 
only by violence transmitted through the femur, the bone may be simply 
fissured, or the head of the femur may be driven entirely through into 
the cavity of the pelvis. In the slighter cases the continuity of the 
pelvic ring is not broken, but in the more extensive ones it is. In 
young people the lines of fracture may follow those of the developmental 
division of the bone into three. 

The displacements are seldom great, but complications are numerous 
and serious. The most frequent is rupture of the urethra, usually in its 
membranous portion ; among the others are rupture of the bladder and 
laceration of the iliac veins or the external iliac artery. Rupture of the 
bladder may be intra- or extra-peritoneal; in some cases it appears to 
have been caused by the direct pressure upon the bladder of the object 
which caused the fracture, in others by a splinter or the displaced frag- 
ment. The other two lesions mentioned are due to the displacements. 
The separation of the pubes tears the urethra across at or near the tri- 
angular ligament, and the projecting edge of the posterior line of fracture 
lacerates one of the iliac veins, or the edge of the anterior one tears the 
external iliac vein or artery. 

In 'a case referred to briefly by Legros Clarke 1 there were several 
fractures, and separation of the sacro-iliac synchondrosis on each side 
and of the pubic symphysis to the extent of four inches. > The rectum 
was ruptured and feces were extravasated into the pelvis ; the bladder 
was ruptured and the urethra torn completely from the prostate gland. 

The varieties and the symptoms which vary notably with them require 
separate mention. 

Separation of the symphysis pubis, which, like fracture or diastasis of 
the costal cartilages, falls directly within the classification, may be pro- 
duced by external violence acting directly upon the pubic arch or through 
forced abduction of the thighs, or by the descent of the foetus through 
the superior strait in parturition. Malgaigne collected seventeen cases 
of the latter, most of them occurring in primiparae, and most by the un- 



1 Diagnosis of Visceral Lesions, p. 339. 



474 FRACTURES OF THE PELVIS. 

aided action of the patient's muscles; in a few cases the forceps were 
used. Usually the separation takes place with a distinct cracking sound, 
and the gap can be felt with the finger, and in one or two cases the frac- 
ture has been made compound by simultaneous laceration of the soft 
parts. The gap is the chief diagnostic symptom. The scanty informa- 
tion possessed upon the subject indicates that, in the traumatic cases at 
least, the separation takes place not between the cartilages, but between 
the cartilage and the bone. 

The traumatic cases are less numerous and more varied in their de- 
tails, although in a large proportion of them the force seems to have been 
exerted through the adductor muscles of the thighs. In two cases quoted 
by Malgaigne, in a third reported by Weber, 1 and in a fourth by Earle, 2 
the patient was on horseback and received the injury either by being 
thrown forward upon the withers, or first to one side and then to the other, 
or by the muscular effort made to keep his seat. In one of Malgaigne's 
cases the results were an immediate hernia, rupture of the perineum 
with a separation at the symphysis that would admit the hand, and pain 
at each sacro-iliac synchondrosis. This patient recovered in three and 
a half months, the treatment consisting of a bandage drawn tightly about 
the pelvis, with the limbs resting upon a double inclined plane. 

In Earle's case there was collapse, severe pain, flattening of the 
pubes, and free bleeding from the anus. An incision in the perineum 
gave exit to blood and urine. The patient survived for only forty hours, 
and the autopsy showed a separation of three inches at the symphysis, 
the left sacro-iliac synchondrosis gaping one inch, and the prostate torn 
completely away from the bladder and hanging down in a cavity filled 
with clot. The patient was between 60 and 70 years of age. 

In another singular case quoted by Malgaigne the patient, a lad 18 
years old, was learning to be a dancer. His teacher made him lie upon 
his back on the floor with his thighs flexed, and then standing upon him 
with one foot on each knee, sought to force the thighs outward. It 
caused the bones to separate at the symphysis to the extent of half a 
finger-breadth. 

In a case reported in the Lancet, 1865, vol. ii. p. 348, a man 41 
years old was run over by a heavy dray, the wheel crossing the upper 
portion of the thigh and lower part of the abdomen, and died in three 
days. There was separation at the symphysis to the extent of three 
inches which could be closed by pressure on the sides of the pelvis ; the 
adductor longus and gracilis were torn at their origin ; there was a frac- 
ture of the pubis on each side at the pectineal eminence, running into 
the acetabulum, and the sacro-iliac synchondrosis gaped widely. The 
urethra was lacerated u a little anterior to the membranous portion." 

In the case reported by Lente, 3 a lad 18 years old was crushed be- 
tween two cars, and the right pubis displaced backward half an inch. 
The bladder was ruptured and the patient died in two days. 

In Sir Astley Cooper's 4 case a quantity of gravel fell upon the back of 

1 Gaz. Med. de Strasburg, 1872. 

2 Med. Chir. Trans., vol. xix., 1835, p. 257. 

3 New York Journal of Medicine, May, 1850, p. 286. 

4 Loc. cit., p. 144. 



FRACTURES OF THE RING OF THE PELVIS. 475 

the patient, who was 22 years old, as he was stooping, and caused sepa- 
ration at the symphysis to the extent of about two finger-breadths. The 
patient experienced violent pain in the region of the bladder and said 
that the urine he first voided was bloody. The catheter was introduced 
and the urine found to be clear. He recovered in three months, with 
some slight separation remaining and lack of symmetry in the position 
of the spinous processes of the ilia. 

In a case reported by Gay, 1 a young man fell while drunk from a 
second-story window and broke his right thigh. By pressing back upon 
the ilium the symphysis pubis could be separated half an inch. There 
was complete retention, and hemorrhage from the urethra. The catheter 
brought bloody urine. He was discharged cured in seventy-four days. 

Separation in Front and Behind. — In one of Mr. Earle's cases (loc. 
cit., p. 261, Case 5), there was complete separation of the left os inno- 
minatum, both in front and behind ; the bone was forced up to a con- 
siderable extent, and the common iliac vein torn across. The patient 
was a young man, and received the injury by jumping from a third story ; 
he landed upon the left foot, causing also a compound comminuted frac- 
ture of the calcaneum and astragalus. 

Similar cases were collected by Malgaigne, and two have been recently 
published by Salleron. 2 The injury has been caused by a fall upon one 
foot or upon the side of the pelvis, or by the pressure of a heavy 
weight upon the front of the pelvis. The characteristic symptom is the 
elevation of the corresponding half of the pelvis with absence of the 
crepitation which is usually present in double vertical fracture. The 
thigh is rotated outward and the limb apparently shortened, and the in- 
jury has been mistaken for fracture of the neck of the femur. The 
error could probably be avoided by careful measuring and by localizino; 
the painful points. Salleron was able to reduce the dislocation in his 
cases, and both recovered, but as a rule the prognosis is extremely grave. 

Separation of the Sacro-iliac Synchondrosis. — Simple separation of 
this joint is very rare. Malgaigne (loc. cit., vol. ii. p. 777) quotes one 
case of it, and four others in which there was in addition fracture of the 
ilium. In the one simple case, reported by Philippe, 1768, the injury 
was caused by the fall of a sack of grain weighing 350 pounds upon the 
patient, who was standing with his back bent. He was able to continue 
his work, feeling no inconvenience except a slight local numbness. On 
the third day the pain returned, paraplegia followed, and he died on the 
twentieth day. 

In a case diagnosed as such by Salleron (loc. cit., 3d Case) the patient, 
a man 28 years old, was thrown forward upon his face by the fall upon 
his back of a mass of limestone from a height of three or four yards. 
The diagnosis was made upon the displacement of the posterior spine of 
the ilium, the pain, and the absence of signs of fracture at any point. 
The patient recovered. 

The lesion is said also to have been produced during labor. 

Separation of all three Joints. — A few cases have been reported as 

1 Boston Med. and Surg. Journal, 1876, April 13, p. 415. 

2 Archives Gen. de Med., 1871, vol. ii. p. 34, Cases 1 and 2. 



476 FRACTURES OF THE PELVIS. 

such, but in most there has been also fracture at one or more points, and 
the separation of one or both of the sacro-iliac synchondroses has been 
only the gaping of the joint due to the lateral separation of the two halves 
of the pelvis and not a real displacement. Malgaigne quotes briefly five 
cases in four of which there were associated fractures of the pelvic 
bones. Dolbeau, 1 Dubrueil, 2 and Pollock 3 have since reported others. 
Dubrueil's is the only one in which there seems to have been actual dis- 
placement at all three points, and even in it there was also a slight frac- 
ture. The patient w T as run over by a wagon. There was separation of 
two and a half inches at the symphysis pubis and gaping of both sacro- 
iliac synchondroses. The sacrum was displaced forward, projecting at 
the level of the superior strait two centimetres in front of the right ilium 
and one and a half in front of the left. There was a fracture at the 
junction of the right ischium and pubis, and partial fracture of the body 
of the right pubis. 

In each case the injury w T as caused by extreme violence acting directly 
upon the pelvis, the passage of a heavy wagon, the fall of a heavy object. 
All terminated fatally. 

Fracture of the pubic portion of the pelvic ring, which is the most 
common of all, passes usually through the horizontal ramus Justin front 
of the ilio-pectineal eminence and through the descending ramus near its 
junction with the ischium. The fracture may be oblique or transverse, may 
be double (of one or both pubic bones), or may be associated with separa- 
tion of the symphysis or with other fractures of the lateral or posterior 
portions of the pelvis. As has been already mentioned, rupture of the 
ligaments of one or both sacro-iliac synchondroses with gaping of the joint 
is a frequent accompaniment when the action of the fracturing force is 
momentarily prolonged. 

The displacement is sometimes so marked that it can be easily recog- 
nized by the eye ; in other cases the diagnosis can only be made after 
palpation of the outline of the bone which is quite accessible to the touch. 

Interference with the voiding of the urine, either by rupture of the 
urethra or by pressure upon it, is a very frequent complication ; Rose, 4 
indeed found it absent in only 1 of 10 certain cases. In a case which 
came under my care at the Presbyterian Hospital, in which both rami of 
the left pubis had been broken, with slight displacement upward of the 
inner fragment, by the caving in of an embankment, there was no injury 
to the bladder or urethra ; the patient recovered. 

Injury to the urethra takes place usually in the membranous portion, 
but occasionally behind or in front of it. The bladder, too, has been 
sometimes torn by a fragment or ruptured by pressure. 

The following are the more noteworthy complications and varieties 
that have been recorded. A man, 20 years old, was run over by a rail- 
way train and received a fracture of the crest of the right ilium, the 
ramus of the left pubis, and of the " right pubis close to its junction 
with the iliac portion of the bone, the sharp end of this fracture had 
entirely divided the external iliac artery." 5 A man, 43 years old, 

1 Gazette des Hopitaux, 1868, p. 194. 2 Id., 1871, p. 413. 

8 The Lancet, 1872, vol, ii. p. 409. 4 Chariteannalen, vol. xiii. part 2. 

5 Lancet, 1878, vol. i. p. 347, Case 2. 



FRACTURES OF THE RING OF THE PELVIS. 



477 



was run over by a wagon, was brought to the hospital insensible, and 
died in three hours. There was fracture of the " ramus and body of the 
pubis on both sides, and separation of the sacrum from the left os in- 
nominatum. Fracture of the left ilium, the fracture extending across 
the pectineal line and causing laceration of the left external iliac vein." 1 
A man was crushed under a heavy iron door and received a fracture of 
the body of the pubis on each side, traversing the ascending rami of the 
ischia. " The pubes were greatly depressed and the urethra was torn 
across through the muscular part just beyond Camper's ligament which 
remained entire." 2 

The following are quoted from Malgaigne. Nivet presented to the 
Societe Anatomique a specimen of double fracture of the ramus of the 
pubis ; the detached fragment had been displaced in front of the body 
of the bone, and had torn through the skin in the fold of the thigh. 
Maret saw a case of fracture of the body of the pubis in which the frag- 
ment, displaced forward and inward, prevented the introduction of a 
catheter. He made an incision on the inner surface of the labium 
majus and withdrew the fragment which consisted of almost the entire 
body of the pubis. The patient recovered and *bore children safely 
afterwards. In a case treated by Nelaton, a fragment perforated the 
bladder and vagina and was removed through the latter. 

Fracture of the lateral portion of the ring occurs in two principal 
forms, one in connection with fracture of the pubic portion, the ether a 

Fiff. 260. 




Double vertical fracture of the pelvis ; uuited. 



fracture radiating from the cavity of the acetabulum. The former is the 
one to which attention was first called by Malgaigne under the title of 



1 Idem, Case 3. 



2 Earle in Med. Chir. Trans., vol. xix., Case 4. 



478 FRACTURES OF THE PELVIS. 

double vertical fracture of the pelvis, and a variety of which has been 
described at much length by Yoillemier (vide supra) as vertical fracture 
of the sacrum. The posterior line of fracture lies either in the ilium 
entirely behind the acetabulum, or in the sacrum, or partly in the ilium 
or sacrum and partly in the sacro-iliac synchondrosis, and sometimes the 
sacrum is crushed rather than fractured. The most prominent symptoms 
in these cases are in the position of the leg and in the extent to which 
it can be moved. The femur is attached to the portion of bone which is 
intermediate between the two lines of fracture, and as this piece is 
usually displaced upward, there is apparent shortening of the limb. At 

Fig. 261. 



ifl^te^ 




Double vertical fracture of the pelvis. 

the same time the piece is commonly rotated about an antero-posterior 
axis so that the upper part of the pelvis is broadened and the lower part 
narrowed. The inability to move the limb is clue in part to the lack of 
a solid support and the fear of pain, and in part perhaps to laceration 
of the muscles of the iliac fossa. The fracture is produced commonly 
by violence acting directly upon the ilium, as in the passage across it of 
a heavy body or in a fall. The prognosis is unfavorable because of the 
probability of associated injuries, but if these do not exist, there is little 
in the fracture itself to endanger life. It may result in lameness or in 
a permanent change in the shape of the pelvis, which, as in the following 
case quoted by Malgaigne from Papavoine, may have the most serious 
consequences. A woman, 34 years old, was kicked by a horse upon the 
right side of the pelvis and received a double vertical fracture, the ante- 
rior one in the usual place, the posterior one on the ilium a little in 
front of the sacro-iliac spmphysis. She recovered in four months, but 
the fragment had united in such a manner that the transverse diameter 
of the superior strait measured 5J inches, and that of the inferior strait 
only 2f inches. Two years afterwards she returned to the hospital to 
be connned. She had previously had five simple labors, but this time 
she was delivered only on the fourth day and with the aid of forceps. 
The necessary tractions were so violent that she received, in addition to 
other very grave injuries, a fracture of the right ischium, and died two 
days afterwards. 

In a case reported by Panas 1 there was a double fracture on each 

1 Gazette des Hopitaux, 1868. p. 180. 



FRACTURES OF THE RING OF THE PELVIS. 479 

side. The patient was a man 35 years old, who was brought to the 
hospital after having been run over by a heavy wagon, and died in 
thirty-six hours. There was no deformity of the pelvis, but crepitation 
could be felt. On the right side the anterior fracture crossed both 
branches of the pubis at the inner side of the foramen ovale, and the 
posterior fracture began two centimetres from the posterior superior 
spine of the ilium and passed into the lower part of the sacro-iliac syn- 
chondrosis. On the left side the anterior fracture was at the outer 
border of the foramen, and the posterior one involved the base of the 
sacrum at its upper part and passed thence into the sacro-sciatic notch 
at the bottom of the synchondrosis. The bladder was ruptured pos- 
teriorly. 

The second form of lateral fracture of the pelvis, radiating fracture of 
the acetabulum, is produced by violence acting through the femur, and 
is quite rare, although Dupuytren says he has met with it a number of 
times. The fracture may be no more than a simple fissure, or the head 
of the femur may be driven entirely through into the pelvis. Dr. Agnew 
refers to a preparation in the collection of Dr. Neill in which the lines 
of fracture follow those of the embryonal division of the bone : the union 
is complete, and there is very little callus on the articular surface. 

Mr. Travers 1 expressed the opinion in a paper read before the Medico- 
Chirurgical Society that the symptoms of fissured fracture were acute 
pain provoked by pressure upon the spine of the pubis and inability of 
the patient to stand, but as the diagnosis in the two supposed cases upon 
which his paper was based was not verified by autopsy, his interpreta- 
tion of the symptoms is open to question. 

The symptoms of the more severe variety, that in which the head of 
the femur is driven more or less completely through into the pelvis, have 
varied considerably in the different cases, and the diagnosis has not 
always been made during life. Sometimes there is outward rotation, 
fixation, and extreme pain on motion ; in other cases the movements of 
the limb are quite free and painless within certain limits. Shortening 
is slight or absent, the trochanter is sunk, and there is absence of cre- 
pitus. Interesting fatal cases have been reported by Drs. Neill, 2 Sands, 3 
and Lawson. 4 

A remarkable case, which will serve to illustrate the possibilities of 
repair, is one reported by Mr. Moore. 5 A man received a severe injury 
of the hip, thought to be fracture of the neck of the femur ; he recovered 
and was able to walk with only a slight limp. At the autopsy several 
years afterwards the injury was found to have been a fracture of the 
pubis, ilium, and acetabulum, which allowed the head of the femur to 
pass through into the pelvis, the trochanter resting against the aceta- 
bulum (fig. 262). 

Similar cases are those reported by Lendrick and Morel-Lavallee. 

1 Lancet, 1854, i. p. 211, and Holmes's Syst. of Surg. 

2 Trans. Coll. of Physicians Philada., vol. ii. p. 267. 

3 N. Y. Med. Record, 1877, p. 93. 

4 Lancet, 1878, i. p. 382. 

5 Med.-Chir. Trans., vol. xxxiv. p. 107. 



480 



FRACTURES OF THE PELVIS. 



Fig. 262. 




Head of the femur driven through the 
acetabulum. 



Lendrick's 1 case was that of a man known as the Wandering Piper, who 
received a severe injury thought to be a fracture of the neck of the 

femur, and died several years afterwards 
of phthisis, having been able to make much 
use of the limb in the mean time. The head 
of the femur was found projecting into the 
pelvis through a rent in the acetabulum. 
A bony case had been formed for it, but a 
portion about the size of a shilling was un- 
covered except by ligament. The pubis 
had also been broken and had united with 
much overlapping. 

In Morel-Lavallee's 2 case the injury was 

thought to be a fracture of the neck of the 

femur. The autopsy, made long afterwards, 

showed multiple fracture of the pelvis united 

with displacement ; the head of the femur 

penetrated to the distance of more than an 

inch into the pelvis and raised the obturator nerve, the stretching of 

which appeared to have been the cause of the sharp pains which had 

been attributed during life to coxalgia. 

Vertical fractures of the sacrum are not known except in connection 
with fractures of the pelvic ring at other points, as already mentioned. 
A few cases of very extensive injury have been recorded, extensive 
crushing and multiple fractures. All proved fatal. 

The course and prognosis in all these cases depend mainly upon the 
lesions associated with the fracture. The only additional point which 
requires mention is one referred to by Legros Clark, the tendency to 
suppuration in the loose connective tissue between the pubes and the 
bladder, especially after fracture of the pubis or separation of the epi- 
physis. The uncomplicated and simpler forms of fracture tend to easy 
repair, and even fractures that are very extensive are by no means 
necessarily fatal, as is proved by many specimens. 

Diagnosis. — The diagnosis is usually easy but may be very obscure 
if the fracture is limited and without much displacement. The outline 
of the pubis should be carefully followed with the finger to detect 
irregularity or localized pain, and pressure should be made backward 
alternately with either hand upon the anterior portion of each ilium in 
the search for abnormal mobility and crepitus. In vertical fracture of 
the sacrum or in separation of the sacro-iliac synchrondrosis displace- 
ment will change the position of the posterior spine of the ilium. In 
double vertical fracture the intermediate portion, which bears the ante- 
rior superior spine, is usually displaced upward, and the displacement 
is easy of recognition and can be diminished or perhaps reduced by 
traction upon the leg. Fissured fracture of the acetabulum would 
probably pass unrecognized, or, at the most, be only suspected from the 
history of a fall upon the trochanter, knee, or foot with pain in the joint 



i Lond. Med. Gazette, vol. xxiii., 1838-39, p. 828. 
2 Quoted by Malgaigne, loc. cit . , vol. ii. p. 881. 



TRANSVERSE FRACTURE OF THE SACRUM. 481 

and the absence of dislocation or of fracture of the femur. Fracture of 
the acetabulum with displacement of the head of the femur into the 
cavity of the pelvis will probably be recognizable by palpation of the 
iliac fossa through the anterior abdominal wall or by digital or manual 
exploration through the rectum. 

Treatment. — Reduction has sometimes been made by lateral pressure 
or by traction upon the thigh, especially after separation of the epiphy- 
sis or double vertical fracture, and the effort when practicable should of 
course be made. The means of retention are limited mainly to a ban- 
dage or girdle drawn snugly about the pelvis and to rest in the dorsal 
recumbent position. Continuous extension, as in the treatment of frac- 
ture of the thigh, may be useful in double vertical fracture or fracture 
of the acetabulum to prevent displacement upward. 

Treatment of the complications belongs more properly to the subject 
of general surgery, but the frequency of laceration of the urethra and 
the advantages of its early recognition and treatment are so great 
that it deserves mention. On the first indication of probable injury to 
the urethra the catheter should be introduced, and if its passage is pre- 
vented or even rendered difficult by injury to the urethra, an incision 
should be made through the perineum to the injured part, cutting upon 
the end of the catheter as a guide. It is entirely unnecessary to pro- 
long the incision to the neck of the bladder, as recommended by some, 
in cases in which the injury is limited to the urethra. If the bladder 
itself has been ruptured cystotomy may be required, but under other 
circumstances it is necessary only to afford a free outlet to the urine 
at the lacerated part of the urethra. The subsequent treatment of the 
urethra is the same as after external perineal urethrotomy for stricture ; 
a full-sized instrument must be passed at intervals of about a week. 

2. Transverse Fracture of the Sacrum. 

This rare injury is produced by blows or falls upon the corresponding 
region, and appears in all cases to have occupied the lower half of the bone 
and to have been produced by the forcible bending inward of its apex. 
Its direction is practically transverse. Malgaigne has reported one case of 
oblique fracture ; in it the violence was received upon the side of the 
bone, and there were also two incomplete transverse fractures. 

The usual displacement is an angular one, the coccyx and lower frag- 
ment being drawn forward so that the apex of the angle is directed 
backward at the seat of fracture. The displacement is due in part to 
the fracturing force and in part to the action of the attached muscles. 
In a case that came under my observation at Bellevue Hospital there 
was extensive sloughing over the sacrum and denudation of the bone, 
apparently due to the direct violence that caused the fracture. The 
same complication is mentioned in two of the five cases collected by 
Malgaigne, both terminating fatally. 

The symptoms are pain at the seat of fracture, both spontaneous and 
provoked by pressure or movements of the trunk, or by the act of de- 
fecation, or perhaps by the act of coughing ; the displacement if present ; 
31 



482 FRACTURES OF THE PELVIS. 

and abnormal mobility and crepitation recognized by grasping the lower 
fragment between the thumb and a finger introduced into the rectum. 

Agnew 1 says " there will probably be present paralysis of the bladder 
and rectum, both of these organs receiving nerves from the sacral 
plexus," and Lossen 2 says that when there is complete displacement 
of the fragment paralysis of the lower extremities, bladder, and rectum 
is never absent, but neither author quotes any cases in support of the 
statement. In the one case that has come under my own observation, there 
was almost complete paralysis of the lower limbs, bladder, and rectum, 
which now, nine months after the accident, has been recovered from in 
great part. 

Burlingham 3 reported a case which he thought to be a comminuted 
fracture of the outer surface of the bone not involving its entire thick- 
ness, with much laceration of the soft parts and flow of urine through 
the wound. The patient made an incomplete recovery, and the nature 
and extent of the injury remain obscure. 

In Bermond's case, quoted by Malgaigne, the fracture was near the 
coccyx, and the lower fragment was displaced so far forward that the 
ringer could not be passed into the rectum until after a female catheter 
had been introduced as a guide. The pain was extreme, was relieved 
by the reduction of the displacement, and returned as soon as the finger 
was withdrawn. 

Treatment. — Unless there is marked displacement, no treatment is 
required beyond the use of pads or rings to relieve the lower fragment 
from pressure. In some cases the surgeons have sought to diminish the 
pressure by flexing the thighs and supporting them upon pillows piled 
up under the knees. 

In two cases the surgeon tried to make direct pressure upon the 
lower fragment by dressings introduced into the rectum. Judes, quoted 
by Malgaigne, used a cylinder of wood five inches long and one inch in 
diameter with graduated compresses outside and a T- bandage to support 
the whole. Bermond filled the rectum with a bag of lint, which soothed 
the patient's pain but had to be removed on the following day to allow 
the bowels to be emptied. He then used a shirted canula through which 
the gas and feces could be passed at will while the rectum was kept 
distended by the tampon. It was removed temporarily on the seventh 
day, and finally on the nineteenth, when abnormal mobility could no 
longer be detected. 



3. Fractures of the Coccyx. 

There is but little definite knowledge concerning this lesion. The first 
mention of it appears to be that of Cloquet in the statement that when 
in old people union has taken place between the different portions of the 
coccyx, and between it and the sacrum, the coccyx might be broken by a 
fall upon the buttocks or, as in a case which he had seen, by a kick upon 
the same part. He refers also to another case in which caries of the 

1 Loc. cit., p. 922. 2 Deutsche Chirurgie, Lief. 65, p. 7. 

3 Am. Journal Med. Sciences, Apl. 1868. 



FRACTURE OF THE ILIUM. 483 

coccyx followed its fracture, but, as Malgaigne says, it does not appear 
that Cloquet verified the fracture. Within a few years several cases 
have been published, and it is furthermore possible that some of the cases 
described as dislocations of the coccyx may have been fractures. None 
of the cases of fracture mentioned have been described with any details, 
and there is, therefore, nothing to be said except that the diagnosis must 
be made as after fracture of the sacrum, and that probably no treatment 
would be required except to reduce displacement. The few recorded 
cases of dislocation have been marked by extreme pain relieved promptly 
by reduction : and in only one was there any tendency to reproduction 
of the displacement. 

Severe persistent pain in the region of the coccyx, coccygodynia, 
sometimes follows a blow, and it is possible that in some of the cases the 
bone may have been broken. Dr. Mursick 1 removed a portion of the 
coccyx in two such cases, and says the same practice has been followed 
by others with good results. Dr. x\gnew's suggestion that such cases 
should be treated first in accordance with the method introduced by 
Simpson, subcutaneous division of the attachments of the coccyx to the 
underlying soft parts, will commend itself to all. 

4. Fracture of the Ilium. 

Fractures of the expanded upper portion of the ilium are compara- 
tively frequent and vary widely in their position and extent ; the more 
extensive ones pass transversely or obliquely from before backward at 
some distance below the crest and are associated sometimes with vertical 
lines which divide the upper fragment into two or more portions. Mal- 
gaigne says that when the fracture lies near the crest it begins com- 
monly at a triangular prominence on the crest near its middle, and runs 
thence backward or forward, or in both directions, following a curved 
line the concavity of which is directed upward. The fracture may be 
limited to a small portion of the rim of the bone, as the anterior superior 
spinous process or the outer lip of the crest. In a unique case observed 
by Dr. Hamilton, the posterior superior spinous process was broken off 
by a fall upon the back ; and Riedinger and Linhart 2 have shown experi- 
mentally that the anterior inferior spinous process can be torn oft* by 
putting the Y-ligament of the hip-joint upon the stretch. In a case re- 
ported in the Bulletins de la Socie:e Anatomique, 1867, p. 283, the 
anterior superior and inferior spinous processes were broken off while 
still in the condition of epiphyses by the passage of a wagon. The 
patient was fifteen years old. 

The cause has heretofore been thought to be direct violence exclu- 
sively, but Dr. Hamilton has reported a case of fracture of the anterior 
superior spinous process by muscular action, and the same agency 
appears not improbable in other fractures of the same part. Riedinger 
asserts the same cause in many fractures of the crest, but brings no 
clinical or experimental facts to demonstrate the correctness of the 

1 Am. Journal Med. Sc, Jan. 1876, p. 122. 

2 Langenbeck's Archiv, vol. xx. p. 451. 



484 F RACTURES OF THE PELVIS. 

opinion. Considering the strength of the muscles attached to the ilium 
and the occasional correspondence of the fragments to the insertions of 
the muscles the theory does not seem unreasonable. 

Symptoms. — The usual signs of pain and swelling are increased by 
the associated bruising of the overlying soft parts, abnormal mobility 
and crepitation can be felt on manipulation at times, but their manifesta- 
tion depends upon the position of the fragment, the posture of the patient, 
and the contraction or relaxation of the muscles. In a case under my 
care where a large fragment composed of the anterior half of the crest 
and the adjoining bone had been broken off by a fall, mobility and crepi- 
tation would at times disappear entirely, apparently in consequence of 
slight changes in the position of the fragment. In other cases extension 
of the thigh prevented mobility, apparently by making the iliacus in- 
ternus muscle tense. In seeking for mobility and crepitation the abdo- 
minal muscles should be relaxed by bending the body forward and to 
one side, and the thighs should be flexed on the pelvis. 

The patient is usually unable to walk, because of pain or of the sense 
of a lack of support. The displacement in the case of fracture of the 
anterior superior spinous process is downward in the direction of the 
sartorius muscle, and in one recorded case of fracture of the crest the 
fragment was drawn upward nearly to the ribs. 

The course is usually a simple one, and the patients are sometimes 
able to leave their beds in two or three weeks. In some very excep- 
tional cases where the violence has been extreme fatal injury has been 
done to the viscera, such as perforation of the intestines by a splinter or 
laceration of the iliac veins ; and suppuration has sometimes taken place, 
probably in consequence of comminution and necrosis of a splinter, 
although in a case of fracture near the crest which came under my care 
a few w T eeks after the accident, and after the abscess had opened exter- 
nally I was unable to find any splinter on exploration of the seat of 
fracture with the finger. In Duverney's case, cpioted by Malgaigne, the 
patient died on the fortieth day in consequence of profuse suppuration 
which filled the entire pelvis. 

The treatment is simple, rest in bed in the position which gives most 
ease and is most favorable to the relaxation of the muscles which would 
be likely to cause displacement. The attempts that have been made in 
the few recorded cases of fracture of the spinous processes to keep them 
in place by pressure with pads and bandages have been entirely unsuc- 
cessful. A circular body bandage is thought by Malgaigne to be harmful 
rather than advantageous because it favors displacement of the fragment 
inward. Hot fomentations or poultices may be required to combat inflam- 
mation at first. In consideration of what appears to be an exceptional 
tendency to necrosis on the part of the fragments of the bone it will be 
proper in compound fractures to remove all detached or loose fragments. 

5. Fracture of the Ischium. 

This is one of the rarest of the fractures of the pelvis. Malgaigne 
collected only six cases, and the list has not been since increased by any 
reported in detail. In some of the cases almost the entire ischium was 



FRACTURE OF THE PUBIS. -185 

broken off. in others only the tuberosity. In three of Malgaigne's cases 
the cause was a fall upon the buttocks, the fourth was a gunshot frac- 
ture, the fifth was caused by an explosion, and the sixth was the one 
mentioned above of a woman who had recovered from a double vertical 
fracture of the pelvic ring with a displacement that narrowed the inferior 
strait so much that two years afterwards delivery could be effected only 
with the aid of forceps, and the ischium was broken in the effort. In 
two of the cases the fracture was comminuted, and in one of them also 
compound, in the other the scrotum was lacerated and the urethra torn, 
presumably by violence received at the same time upon the perineum 
and not by displacement of the bone. In a case described by Sir Astley 
Cooper 1 and quoted by Hamilton as a fracture of the ischium with rup- 
ture of the urethra, caused by the passage of the wheel of a cart, the 
fracture was probably of the pelvic ring and not of the ischium alone. 
In the simple cases there was little or no displacement ; in the gunshot 
fracture the fragment was displaced downward more than two inches by 
the contraction of the hamstring muscles. The displacement persisted, 
but does not appear to have interfered materially with the movements of 
the limb. All except the sixth recovered. 

Mobility and crepitation can be recognized by manipulation of the 
bone, preferably with the finger in the rectum or vagina. The severity 
of the pain depends upon the violence and the associated injuries and 
makes it difficult for the patient to walk. 

No treatment is required except rest in bed with pillows or air-cushions 
so arranged as to prevent pressure upon the broken bone. If the patient 
lies upon the side the knees may be kept flexed to relax the muscles 
which are attached to the ischium. 

6. Fracture of the Pubis. 

In almost all cases of its fracture the pubis is so broken that the con- 
tinuity of the pelvic ring is destroyed ; the cases in which only one 
ramus has been broken, or in which a lateral fragment has been broken 
off are extremely rare, and consequently there is but little to be added 
to what has been already said in the first portion of this chapter. The 
only cases of this limited fracture of which I have any knowledge are 
one reported by Nivet, and one by Cappelletti. In Nivet's 2 case, the 
account of which is not quite clear, there appears to have been a double 
fracture of the descending ramus, the intermediate piece was displaced 
forward and had torn the skin of the groin. In Cappelletti's 3 case a 
man jumped from a carriage, alighting upon his feet with one limb widely 
abducted. Six months afterwards there was still some swelling at the 
anterior superior part of the right thigh, and a fragment of bone about 
two and a half inches long and as large as the finger could be felt there. 
Cappelletti was convinced that this'fragment was a portion of the descend- 
ing branch of the pubis and the ascending branch of the ischium detached 

1 Fracts. and Disloc, Am. ed., p. 140, Case 74. 

2 Bull, de la Societe Anatomique, 1837, p. 194. 

3 Ranking's Abstract, vol. viii., 1848, p. 91. 



486 FRACTURES OF THE PELVIS. 

by muscular action. The pelvis appeared to be defective anteriorly at 
the point corresponding to the supposed original seat of the fragment, 
there was acute pain on pressure at the swelling and at the tuberosity of 
the ischium, the patient walked limping and with pain, and the pain was 
increased by abduction of the limb. 

7. Fracture of the Rim of the Acetabulum. 

This is a lesion which sometimes accompanies partial or complete 
dislocation of the femur upon the pelvis. Malgaigne says the first re- 
corded case was observed by Sir Astley Cooper in 1805, but does not 
give the reference. In Cooper's Dislocations and Fractures (Am. edi- 
tion, p. 137) an account is given of a case admitted into Guy's Hospital 
in 1791, under the care of a surgeon who is not named, in which the 
character of the injury was made known by post-mortem examination. 
The posterior part of the acetabulum was broken off, and the head of 
the thigh bone had slipped from its socket. There were other fractures 
of the pelvis on both sides, laceration of the kidney, and abundant 
hemorrhage into the cavity of the abdomen. A sufficient number of 
cases have since been observed and reported to make the history of the 
lesion complete. 

The upper and posterior portion of the rim is the part most frequently 
broken, and the accompanying dislocation is commonly backward. In 
one of M'Tyer's cases 1 there were two fragments, and in Maisonneuve's 
case three, but in this latter the fracture was much more extensive. In 
another case (M'Tyer) the fracture had united with but slight displace- 
ment, and the ligamentum teres was untorn. 

The symptoms, when the case first comes under observation, are those 
of simple dislocation backward, and the complication of fracture is recog- 
nizable only by slight crepitation felt on manipulation or during reduc- 
tion and by the easy recurrence of the dislocation after reduction. 
Sometimes the head of the bone slips out of its socket again as soon as 
the traction ceases, in other cases only after the lapse of a few hours or 
on movement of the limb or body. In Maisonneuve's case 2 the disloca- 
tion was incomplete backward, movement of the limb caused distinct 
crepitation, reduction was made by slight traction downward, and the 
displacement recurred promptly when the limb w r as adducted, but not 
when it was kept abducted. 

Malgaigne calls attention to the necessity of making sure of the exist- 
ence of a dislocation, and of not depending for the diagnosis solely upon 
crepitation and easy recurrence of the displacement, signs which may 
accompany fracture of the neck of the femur. The prominent distinc- 
tion between dislocation backward and fracture of the neck of the femur 
is in the position of the limb, which is flexed upon the pelvis and rotated 
inward in the former, and usually straight and rotated outward in the 
latter, but this alone should not be depended upon, the position of the 
head of the bone should be made out. 

1 Glasgow Med. Journal, 1830. 

2 Revue Medico Chirug., vol. xvi. p. 48. Quoted by Malgaigne. 



FRACTURE OF THE RIM OF THE ACETABULUM. 487 

The treatment should be directed to the prevention of a recurrence of 
the dislocation after its reduction. Continuous extension gave a good 
result in one case ; and in Maisonneuve's case in which the tendency to 
dislocation was manifested only when the limb was adducted the sur- 
geon kept the limb partly flexed and widely abducted. The patient 
died on the twenty-seventh day, and the fragment was found to have 
re-united. 



488 FRACTURES OF THE FEMUR. 



CHAPTER XXV. 

FRACTURES OF THE FEMUR. 

The tables in Chapter I. show the great preponderance in number 
of fractures of the upper extremity over those of the lower extremity 
in the combined records of hospital and "out-patient" or Dispensary 
practice. The records of the London Hospital for twenty-six years 
show in a total of 51,938 fractures 27,119 of the upper extremity 
(including the clavicle), and 13,750 of the lower extremity. Of these 
8213, six percent, of the whole, were of the femur. The Berlin and 
Halle records, quoted by Gurlt (Chapter I. Table I.) show in totals of 
232 and 97 fractures of the thigh, 76 and 21 of the neck of the bone 
respectively. The records of Bellevue Hospital for nine years, collated 
by Dr. F. E. Hyde, 1 contained 302 cases of fracture of the thigh, in 
which the position of the fracture was stated, divided as follows: neck 
61, upper third (exclusive of neck) 34, middle third 169, lower third 31, 
of which 7 were of the condyles. Of 236 fractures of the thigh recorded 
by Dr. Hamilton, 84 were of the neck, 30 of the upper third, 86 of the 
middle third, and 36 of the lower third. 

Malgaigne's analysis of 308 fractures (104 of the neck, 207 of the 
shaft) according to age and sex is as follows : — 





Fractures of the Shaft. 






Age. 




Male. 


Fema 


2 to 20 years 




35 


12 


20 " 40 " 




47 


6 


40 " 60 '■ 




43 


15 


60 " 80 " 




20 


29 



145 62 = 207 

Fractures of the Upper Extremity. 



Age. 
4 to 50 years 
50 " 60 kk 
above 60 '* 



Male. 


Female. 


9 


5 


9 


10 


30 


41 



48 56 = 104 

1. Fractures at the Upper End of the Femur. 

In this class are included fractures of the neck of the femur within 
and without the capsule, fractures of the trochanter and separation of its 
epiphysis, and fractures through the trochanter. 

1 N. Y. Medical Record, 1875. 



FRACTURES OF THE NECK OF THE FEMUR. 489 

Dupuytren 1 says that a rather common effect of falls upon the feet or 
the trochanter is the crushing of the head of the femur, the neck 
being left entirely uninjured. The injury passes for a simple contusion 
and the patients recover without deformity. He quotes no cases in sup- 
port of this remarkable statement. The injury, so far as I know, is not 
mentioned by any other writer, and there is no report of any case, and 
no specimen in any museum. 

A. Fractures of the Neck of the Femur. — This is essentially a 
lesion of advanced middle life and old age, and, as the second table 
given above shows, is more common in old women than in old men. It 
is often produced, too, by slight causes, such as a misstep, a stumble, a 
fall upon the knee or hip, and these two facts taken together indicate 
senile change in the bone as a markedly predisposing cause. Examina- 
tion of the thigh bones of old people, those that have been broken and 
those that have not, bears out this indication, for it shows all the parts 
of the bone much rarefied, with thinning of the cortical shell and enlarge- 
ment of the meshes of the spongy tissue. A former theory which at- 
tributed the frequency of fracture to an increase in the proportion of the 
earthy matter of the bone in old age has been shown to be unfounded 
in fact ; the proportion of earthy matter in the bone tissue itself is not 
diminished, the change is in the amount of the bone as compared with 
the intermediate spaces occupied by the bloodvessels and fat, the com- 
pact tissue grows spongy, the spongy tissue grows spongier or more 
like the medullary canal. In one case I found the specific gravity of 
the femur only 1078; the bone was that of a feeble, badly-nourished 
man 40 years old who died three months after having broken the neck 
of the femur at the base by a fall to the ground while walking. This 
change is more marked in old women than in old men. 

Another reason for the greater frequency of these fractures in the old 
has been sought in a change alleged to take place in the angle at 
which the neck joins the shaft. It was asserted that as the individ- 
ual grows older this angle approaches a right angle, a position that 
would favor fracture, but examination has proved this not to be the case. 
Rodet 2 found the average angle in the child and adult 131°, and in the 
old 128°, a difference too small to deserve attention, especially since the 
limits between which the angle ranges normally are wide, 12 L° and 144° 
according to the same author. 

Other points in the connection between the neck and the shaft require 
mention because of their influence in the production of the fracture and 
in the character of the displacement. The antero-posterior diameter of 
the neck is much smaller than that of the shaft, and the two are so joined 
that a large part of the great trochanter lies behind the posterior wall of 
the neck, and, as shown by Prof. Bigelow, 3 it is traversed in part by a 
prolongation of the posterior wall of the neck (fig. 263). This prolonga- 
tion which Bigelow calls the true neck constitutes a vertical septum, " a 

1 Lecons Orales, vol. ii. p. 111. 

2 These de Paris, 1844, quoted by Tillaux and others. 

3 The Hip, p. 121. 



490 



FRACTURES OF THE FEMUR. 



Fig. 263. 




I mm 

! W 

WW 



thin dense plate of bone continuous with the back of the neck, and re- 
inforcing it, plunging beneath the inter-trochanteric ridge in an endeavor 
to reach the opposite and outer side of the shaft. At its lower extremity 
it curves a little forward so as to take its origin, when on a level with the 

lesser trochanter, from the centre instead 
of the back of the cylindrical cavity." 
The posterior part of the trochanter is 
therefore only an apophysis attached to 
the shaft for the insertion of the rotator 
muscles, and the mechanical function of 
the shaft and neck with reference to the 
resistance to strain is practically inde- 
pendent of it. The rarefying senile change 
affects this septum and may remove it so 
completely that it cannot be distinguished 
from the surrounding cancellous tissue. 
Sappey says that he has never seen this 
absorption go so far as to prolong the 
medullary canal into the neck. This 
comparative independence of the trochan- 
ter and the neck invalidates those theories 
of the mode of production of fractures 
which have been based upon the angle be- 
tween their respective axes. 

The capsule is usually attached to the 
femur in front along the spiral line, above 
to the neck a little short of its junction 
with the trochanter, behind to the neck 
itself about half an inch from the inter- 
trochanteric line, and below to the upper 
part of the lesser trochanter. In front 
and below, therefore, the neck lies entirely 
within the capsule, while above and behind 
its outer third or fourth part is external 
to it. These limits vary somewhat in 
different individuals. The synovial membrane does not follow the cap- 
sule closely to its insertion, but is reflected early from it to the neck, leav- 
ing a strip of the latter between the points where it joins the capsule and 
the synovial membrane which although intracapsular is yet extra-articular. 
The periosteum is thick and contains, especially in its upper portion, 
numerous bloodvessels which enter the head and neck by the large fora- 
mina found there. Of these vessels, one in particular, a branch of the 
internal circumflex artery, is of considerable size, runs along the upper 
portion of the neck and enters the head. Wilkinson King 1 has called 
attention to the fact that this portion of the periosteum is frequently left 
untorn in fracture of the neck, and he suggests that this arterial branch 
is probably the one which does the most to preserve the vitality of the 
head of the bone under such circumstances. 




Neck of femur. (Bigelow.) 



1 Guy's Hospital Reports, 1844, p. 347. 



FRACTURES OF THE NECK OF THE FEMUR. 491 

Discussion as to the relative frequency of the different fractures of the 
neck of the femur has turned mainly upon the distinction between the 
so-called intracapsular and extracapsular ones, but the uncertainty of the 
diagnosis during life in a considerable proportion of cases is such that 
reliance cannot be placed upon records unverified by post-mortem exami- 
nation, and the existence of an intermediate class of " mixed fractures" 
which may be arbitrarily added to one or the other makes even the tables 
of specimens somewhat uncertain. Malgaigne, who included the mixed 
among the intracapsular, considered these the more frequent, in the pro- 
portion of three to two, basing the opinion upon the examination of 103 
museum specimens. It is questionable whether museum collections would 
represent the clinical proportions of the two varieties, since the intracap- 
sular fractures attract more attention by their greater permanent disability 
and more commonly hasten death. There is reason to think that in the 
majority of cases the fracture takes place at the junction of the neck and 
shaft, and is accompanied by more or less penetration of the latter by 
the former. This is certainly true of fractures that occur in people who 
are less than 50 years old. 

As a small contribution to the statistics of this subject I add the re- 
sults of my personal experience during one year at the New York Alms- 
house, where fractures of the neck of the femur were quite common. I 
made post-mortem examinations in six cases ; in two of them the fracture 
was purely intracapsular, at the narrow part of the neck, in three the 
fracture was at the junction of the neck and shaft, and in the remaining 
one in which the patient had survived the accident six months the neck 
had entirely disappeared, leaving only the hemispherical head and the 
shaft surmounted by the uninjured trochanter. From the symptoms in 
this case and the appearance of the specimen I believe that in it also 
the fracture was at the base of the neck. The ages were 65, 61, 82, 
66, 40, and 70 years in the order in which the cases have been mentioned. 

Causes. — An important predisposing cause has been mentioned, the 
senile rarefaction which begins usually after the 50th year and is more 
marked in females than in males. 

The common immediate causes are slight falls upon the knee, the side 
of the thigh, or buttocks ; less common are stumbles, missteps, an effort 
to avoid falling, or even, according to Sir Astley Cooper, the slight jar 
caused in stepping down to a lower level, as from the curbstone to the 
crossing. 

It is probable that the action of the muscles or the strain exerted 
through the ligaments in extreme positions of the limb is a more frequent 
cause of fracture than is generally supposed, and that the fall is some- 
times the consequence rather than the cause. A number of cases are 
on record in which the bone has been broken in this manner, and by 
efforts so slight in some of them that they might easily have been over- 
looked if a fall had been associated with them. Malgaigne indeed goes 
so far as to say that he believes most intracapsular fractures are pro- 
duced, even in falls, by exaggerated movements of the thigh, adduction, 
abduction, or rotation. The efforts which have been made to explain 
different varieties of fracture by differences in the direction of the blow 
or in the point at which it has been received have not been satisfactory 



492 FRACTURES OF THE FEMUR. 

either as a demonstration or as an aid in diagnosis. Few patients are 
able to tell exactly how they have fallen, and even if they could do so 
there Avould still be enough uncertainty concerning the extent to which 
muscular action had intervened to vitiate the conclusions that might 
otherwise be drawn from the circumstances of the fall. At the same 
time it should be said that attempts to produce the fracture in cadavers 
by blows upon the knees have always failed, while blows upon the tro- 
chanter usually succeed, the fracture being invariably at the junction of 
the neck and shaft if the body is that of an old person. 1 

Sir Astley Cooper (loc. cit., p. 155) tells of a woman who turned sud- 
denly while standing ; an irregularity in the floor kept the foot from 
following the movement of the body, and this was sufficient to break the 
neck of the femur. He tells also of a woman, 83 J years old, who, while 
walking across the room, accidentally placed her cane in a hole in the 
floor and lost her balance ; she tottered, but was saved from falling by 
those standing near her, and found she had broken her thigh. At her 
death, fifteen months afterwards, the fracture was found to have taken 
place at the junction of the neck and shaft, with deep penetration of the 
former into the latter. (Loc. cit.,p. 177, Case 90.) 

Earle 2 mentions a case in which " the neck gave way within the cap- 
sule from a mere muscular effort in emptying a pail of water, and twist- 
ing the body and pelvis at the same moment, while the lower extremities 
remained fixed." 

Dupuytren 3 refers to the case of a } r oung negro, in whom the neck of 
the femur was broken by the tetanic contraction of his muscles, but the 
case is doubtless the one quoted by Malgaigne, Gurlt, and others, and as 
the fracture was compound, it is probable that the bone was broken be- 
low the trochanter (see Chap. IV. p. 94). 

Malgaigne (loc. cit., vol. i. p. 666} produced a fracture by forced 
abduction of the thigh in an attempt to dislocate the head of the bone 
forward and downward. The cadaver was that of an individual 81 years 
old. He also saw a fracture caused in an old man in an effort to save 
himself from falling by leaning to one side. The effort was accompanied 
by sharp pain in the hip. He speaks of this as a fracture by exag- 
gerated adduction, but gives no other details. Verneuil produced a 
fracture at the junction of the neck and shaft while trying to reduce a 
dislocation ; the patient was an old man. 

Linhart 4 was able to break the neck of the femur by adducting the 
thigh and then forcing the body backward so as to put the ileo-femoral, 
or Y-lig amen t ) 5 upon the stretch; and Riedinger 5 and Stetter 6 have 
recently published cases in which the injury occurred in like manner, the 
patients having bent suddenly backward to save themselves from falling. 
One was 60, the other 14 years old. 

Anatomical Varieties. — The division of these fractures into intra- 
capsular and extracapsular which is supported by the authority of Sir 

l . Hennequin, Des Fractures du Femur, p. 627. 

2 Practical Observations on Surgery, 1822, p. 20. 

3 Lecons Orales, vol. ii. p. 94. 

4 Deutsche Gresellschaft fur Chirurgie, 1875. 

5 Central blatt fur Chirurgie, 1875, p. 817. 6 Idem., 1877, p. 561. 



FRACTURES OF THE NECK OF THE FEMUR. 493 

Astley Cooper and Dupuytren and most of their contemporaries is defec- 
tive anatomically, because of the mixed fractures for which it makes no 
formal provision and which are included sometimes in one and sometimes 
in the other ; x and is objectionable clinically, because the relations of the 
fracture to the insertion of the capsule do not affect the symptoms and 
the prognosis so much as some other differences do, and because the dif- 
ferential diagnosis is impossible in a considerable proportion of cases. 
These objections have been urged by many surgeons ; among them Clo 
quet, Gosselin, Bigelow, Duplay, Bryant, and Lossen may be mentioned 
as representatives of different countries and periods, some of w T hom have 
formally rejected the classification and substituted for it one based 
largely upon the presence or absence of impaction. No one can deny 
the great clinical importance of impaction and its influence upon the 
prognosis, but the condition to which the term is applied in fractures of 
the neck of the femur is not, in my opinion, such as should be made the 
basis of a classification, for the penetration of the fragments is not ordi- 
narily such as fixes them closely together, bat is rather an accident of 
the fracture, one which may or may not be superadded to it, and which 
is at the mercy of careless handling, of muscular spasm, or perhaps even 
of the manipulation necessary to make the diagnosis. Prof. Bigelow's 2 
classification, which is briefly " Impacted fracture of the base of the 
neck, and unimpacted fracture of the rest of the neck," has the great 
merit of making an important clinical distinction, and also recognizes an 
anatomical feature, the position of the fracture at the junction of the 
neck and shaft, which is the essential characteristic of the largest divi- 
sion of these fractures. 

The distinction made by Sir Astley Cooper was actually between frac- 
tures at the narrow part of the neck (intracapsular) and fractures at or 
near the base of the neck (extracapsular and mixed), and it is not to be 
denied that these two varieties differ considerably from each other in 
their symptoms, and very notably in their prognosis. The objection is 
that the names applied to them have been misleading, and the distinction 
has lost the sharpness which it possessed in the minds of those who first 
made it, and therefore, while appreciating highly the desirability of 
retaining names sanctioned by long use, I have yet thought it best, in 
view of the general recognition of the defects of this classification, to 
use terms that define the anatomical position of the fractures somewhat 
more sharply. I shall therefore describe separately (a) fractures of the 
small part of the neck {intracapsular') and (b) fractures at the base of 
the neck (extracapsular and mixed). 

1 Tims Sir Astley Cooper (loc. cit., p. 148) defines as extra-articular " a fracture ex- 
ternal to the ligament through the neck of the thigh bone, at its junction with the 

trochanter major This is often in part within, and in part external to, 

the capsular ligament." While Malgaigne (loc. cit., p. 660) says " II est a noter 
que plusieurs de ces fracture^ obliques se prolongent en dehors au dela des limites de 
la synoviale, et constituent en quelque sorte des fractures mixtes, a la fois intra et 
extra-capsulaires. Mais comme elles ne different pas sensiblement des fractures intra- 
capsulaires avec conservation d'une partie du perioste, je les comprendrai dans la 
meme etude." 

2 The Hip, p. 126. 



494 



FRACTURES OF THE FEMUR 



(a) Fractures of the Small Part of the Neck (Syn. Intracapsular 
fractures ; fractures of the anatomical neck). — The line of fracture may 
be transverse, oblique, or irregular. The surface of the fracture is 
almost always irregular, a large cone of spongy tissue presenting on one 
fragment, usually the head, and a corresponding depression on the other. 
As a result of the interlocking of their irregularities or of the penetration 
of one fragment by the other, the pieces may be retained in contact with 

each other or even so firmly im- 
pacted that considerable force may 
be required to separate them, as 
in a case quoted by Bigelow 
(loc. cit., p. 131), and repre- 
sented in fig. 264. This impac- 
tion or close interlocking is doubt- 
less very rare. The line of frac- 
ture in rare cases passes partly 
through the head of the bone, and 
sometimes the fracture is commi- 
nuted. 

The periosteum of the neck is 
usually left untorn over a portion 
of the periphery, the seat of which 
varies considerably in the diffe- 
rent cases. In a specimen in my 
possession the untorn portion is 
nearly an inch in width, and is 
situated at the lower and poste- 
rior part ; in other reported cases 
it has been behind, behind and 
above, and above and in front. 
A case of complete preservation 
of the periosteal sheath was re- 
ported by Mayor. 1 The patient was an old man who fell while walking, 
and was brought to the hospital. The clinical account is very brief, 
stating only that he presented the well-known signs of fracture near the 
hip-joint, and that the diagnosis could be made on simple inspection of 
the position of the foot. It is probable, therefore, that eversion of the 
limb was marked. He died in a week. On opening the joint no sign of 
fracture could be seen, but after scraping off the periosteum of the neck 
the fracture was found " immediately behind the head and in the form 
of an almost imperceptible fissure." 

A somewhat similar case is reported by Stanley, 2 and, although the 
fracture appears to , have been rather at the junction of the neck and 
shaft, I quote it here to complete the subject. The patient was a man 60 
years old who fell in the street and presented no symptoms of injury at 
the hip except pain. He died in the fifth week of inflammation of the 
bowels. "The head and neck of the bone were sawed through their 




Impacted intracapsular fracture of the neck of the 
femur. (Bigelow.) 



1 Gazette Medicale, 1834, p. 612. 

2 Med. Cliir. Transactions, vol. xiii., 1825, p. 511. 



FRACTURES OF THE NECK OF THE FEMUR. 495 

middle, and in each portion a dark line, evidently occasioned by the effu- 
sion of blood, "was seen extending through the bone at the basis of the 
neck. A fracture was discovered extending along this line ; but the 
broken surfaces were in contact, and the synovial and fibrous membrane 
covering the neck of the bone was uninjured." 

Partial fractures were first reported by Colles, 1 but his interpretation 
of the cases, which are given with scanty details, was questioned by R. 
W. Smith ; and in another alleged case reported by Adams the same sur- 
geon proved by maceration of the specimen that the fracture was com- 
plete. 

A more probable case, although not belonging in this class, is one re- 
ported by Tournel in 1837, and quoted by Malgaigne (loc. cit., p. 43). 
A man, 83 years old, fell and was unable to rise. There was no short- 
ening, no crepitation, nothing but pain in the hip increased by the least 
movement, swelling, and inability to move the limb. The diagnosis 
of intracapsular fracture without displacement was made, and Desault's 
long splint applied. On the 28th day, the pain having ceased and the 
limb maintaining its full length, the diagnosis was changed to contusion 
and the splint removed. A fortnight afterwards there was shortening 
and eversion ; diarrhoea ensued, and the patient died three and a half 
months .after the fall. The autopsy showed an incomplete fracture be- 
tween the base of the neck and the trochanter, constituting a long crack 
which ran down in front and behind from the digital fossa to points a 
little below the lesser trochanter, which remained attached to the neck. 
Below the lesser trochanter was a sort of bony bridge where the bone 
had remained unbroken. The broken surfaces were not in immediate 
contact but were united above by an interposed reddish, bony substance. 

The shortening noted in this case must have been an error of observa- 
tion if the anatomical description is correct. 

Another case was reported by Wilkinson King, 2 the patient was a 
man 72 years old, and died on the 54th day of pneumonia. No men. 
tion is made of the clinical symptoms. " The neck of the left thigh bone 
was nearly divided by fracture at its narrowest part. All that seemed 
to retain the fragments in union was less than one-third of the shell 
superiorly and anteriorly. The head was deflected backwards, and the 
buttress of the neck, which was too thin, was driven into the cancelli 
about a third of an inch. The only trace of new ossification is a point 
on the base of the buttress. There is no certain repair even of the bent 
portion of the shell above." The accompanying figure, which repre- 
sents a section of the head and neck, shows a line of crushing extending 
nearly across the neck close to the head. Considering the age of the 
patient, the extent of the displacement, and the length of the survival, it 
seems probable that the fracture originally extended entirely across, but 
with no displacement except an angular one made possible by the crush- 
ing of the tissue along the line of fracture. The nearer the apex of the 
angle the less would be this crushing, and the minimum at the cortical 
layer might easily be repaired without leaving any trace. 

1 Dublin Hosp. Rep., vol. ii. p. 334, Cases 7, 8, and 9. 

2 Guy's Hosp. Reports, 1844, p. 352. 



496 FRACTURES OF THE FEMUR. 

In an interesting case that came under the care of Prof. Bigelow (loc. 
cit., p. 188) a spiral fissure began at a fracture eight inches below the 
trochanter, " winds upward and inward to the front of the bone, cross- 
ing the anterior intertrochanteric line midway between the trochanters ; 
thence vertically upward to the outer edge of the cartilage ; thence 
transversely across the top of the neck to its posterior surface ; thence 
vertically down behind the neck to a point half an inch from the lesser 
trochanter, terminating on the under side of the neck half an inch from 
the point where the fissure crosses the intertrochanteric line in front. 
The elastic bony pedicle thus formed allows a slight springing motion of 
the head, but maintains it firmly in place." 

Some of the French writers refer to cases by Sabatier and Hervez de 
Chegoin, but I have been unable to verify them. 

Separation of the epiphysis, of the head from the neck, has been sus- 
pected sometimes, and verified once by examination. Bony union of the 
part takes place between the seventeenth and twenty-first years, and in 
the few cases of fracture of the neck of the femur that occur in patients 
of this age, or younger, the question whether the fracture may not fol- 
low the epiphyseal line will naturally arise. Dr. Hamilton quotes six 
cases in which this injury was suspected ; Mr. Hutchinson 1 mentions 
three others, one of them having been under his own care ; and Spill- 
mann 2 quotes one observed by Sabatier and another by Yerduc. The case 
verified by examination, is reported in the Bulletins de la Societe Anato- 
miqne, 1867, p. 283. The patient was fifteen years old, and was run 
over by a wagon. The symptoms were shortening, eversion, and inabil- 
ity to move the limb. The patient died in a few hours. The separation 
was complete along the epiphyseal line, and the head was attached to 
the neck only by a strip ot' periosteum two millimetres wide. The peri- 
osteum was stripped up on the inner and lower part of the neck, and the 
capsule was torn at its inner portion. 

Dr. Johnson 3 gives the history of a case under the care of Dr. Wood, 
which may have been either a separation of the epiphysis or a pure 
intracapsular fracture. The patient was a girl sixteen years old, who 
had been caught between the wheels of two wagons. The fracture 
failed to unite, and at her death, three years later, the head and neck 
were found very soft and partly absorbed. If the lesion was a fracture 
the case deserves mention because of the patient's youth. 

The usual displacement is of the shaft upward, and it is sometimes 
accompanied by laceration of the capsule ; it usually takes place grad- 
ually during the week following the receipt of the injury, and rarely 
exceeds one inch, except after the lapse of a long period of time. I 
have seen it in one case reach two inches in the course of the second 
month. If impaction takes place the head may be twisted about its 
axis, as in fig. 261, or there may be some overlapping, as in fig. 265. 

The sympjtoms are inability to raise the limb or to bear the weight of 
the body upon it, eversion, shortening, at first slight, afterwards increas- 

1 Med. Times and Gazette, 1866, i. p. 195. 

2 Diet. Encyclopedique, art. Cuisse, p. 238. 

3 N. Y. Journal of Medicine, 1857, p. 303. 



FRACTURES OF THE NECK OF THE FEMUR. 



497 



a shorter radius than 



Fig. 265. 



ing, crepitation on manipulation, and possibly the sense when the limb is 
gently rotated that the trochanter moves upon 
usual. These symptoms will be considered 
more in detail hereafter, but a word of cau- 
tion is needed with reference to two of them, 
e version and inability to use the limb. 

Inversion of the foot has been observed 
in not a few cases, and in some has led to 
the diagnosis of dislocation and treatment 
by extension with pulleys. A remarkable 
instance of this was reported by Bevan ; x it 
was observed in the body of an old woman 
brought to the dissecting-room. There was 
half an inch shortening, which could be 
easily increased by pressure on the heel to 
one and a half inches. The foot was slightly 
rotated inward, and could be turned in that 
direction until the toes pointed directly back- 
ward. Outward rotation was possible to the 
usual extent. The fracture was an old one, 
absorbed. 

Similar cases in which the diagnosis was ve rifle 
animation have been reported by many surgeons 




Impacted fracture within the cap- 
sule. (Smith.) (See p. 502.) 

and the neck was entirely 



by post-mortem ex- 
In Stanley's 2 case 
the patient was a middle-aged man, and the injury was caused by a fall 
in the street, the hip striking against the curbstone. There was one 
inch shortening, and inversion ; the injury was thought to be a disloca- 
tion, and extension was made. The fracture was oblique and entirely 
within the capsule. In most of the cases the exact position of the frac- 
ture has remained in doubt, and the subject, therefore, will be referred 
to again in the section on Symptoms and Diagnosis. 

In some cases the patient has been able to move the limb quite freely 
immediately after the receipt of the injury, and even to walk upon it 
with more or less limping and pain. The following are among the most 
marked illustrative cases verified by post-mortem examination. 

A feeble, sickly woman, 3 fifty-six years old, was admitted to the hos- 
pital with erysipelas of the left thigh. Redness and swelling extended 
down to three inches above the patella, and fluctuation was evident on 
the outer and upper part of the thigh. The swelling had appeared 
three days before admission to the hospital, and had been preceded by 
rigors. Three months previously she had fallen on her left side, and 
from that time she had had a slight halt in walking, but the injury had 
not kept her from her usual occupations. 

She suffered much pain in the thigh, measurements could not be made, 
and the limited handling that was possible caused no crepitus. The 
abscess was punctured and discharged freely until her death on the 
eleventh day. The neck of the femur was found to be broken within 



32 



1 Dublin Quarterly Med. Journal, 1850, vol. ii. p. 312. 

2 Med. Chir. Transactions, vol. 13. 

3 McTyer, in Glasgow Med. Journal, 1831, p. 52. 



498 FRACTUKES OF THE FEMUR. 

the capsule, and the ahscess communicated with the joint through a lace- 
ration in the capsule. No other details are given. 

Dr. Wm. Hunt 1 reported a remarkable case. The patient, a man 26 
years old, was struck across the upper portion of the left thigh and groin 
by a heavy piece of timber and fell to the ground. He suffered much 
pain all night and came the next day to the hospital, travelling some 
distance in the cars and walking from the station to the hospital, a dis- 
tance of more than a furlong, with the aid of a stick. The symptoms 
were pain, eversion of the limb, shortening of half an inch, and deep 
crepitus. There was a large bruise on the upper and outer aspect of 
the thigh over the trochanter and the anterior superior spinous process 
of the ilium. A pelvic abscess formed, and he died on the twenty- 
seventh day. 

" The neck of the femur immediately behind the head was broken 
directly across, the lines of fracture being completely within the capsule 
of the joint." 

One of my own patients, a man 65 years old, fell down a flight of 
steps, rose without assistance, walked to and down the next flight, and 
then suddenly found his left leg powerless. Two days afterwards I saw 
him and found half an inch shortening and eversion. He died in the 
third week of erysipelas. The fracture was almost directly transverse 
and close to the head, and a strip of periosteum one inch w T ide on the 
under side of the neck remained untorn. (See also the case quoted 
below from R. W. Smith, p. 502.) 

Repair. — The possibility of the repair of an intracapsular fracture of 
the neck of the femur by bony union has been the subject of much dis- 
cussion for more than fifty years. It began with the assertion by Sir 
Astley Cooper that union was extremely rare, and indeed piactically 
impossible in the common form of the injury, that in which the perios- 
teum is torn. Sir Astley's opinion was generally understood to be that 
bony union was impossible under any circumstances, and as such found 
its principal opponent in Dupuytren. Subsequent authors have ranged 
themselves upon one side or the other of the question, according to their 
interpretation of certain specimens of alleged repair by bony union pre- 
served in public museums or in the possession of private individuals. 
The number of these specimens and of reported cases is quite large, 
probably between forty and fifty, and the questions that arise concerning 
them are : 1st. Has the bone been broken, or is the condition due only 
to absorption of the neck ? 2d. Was the fracture a pure intracapsular 
one ? 3d. Is the union bony ? 

The first question arises in only a few cases, some specimens found in 
the dissecting room without history. Sir Astley Cooper refers to two 
found by Mr. Stanley in one subject, and evidently considers it more 
unlikely that a man should break both thigh bones and get well than 
that senile absorption should take place in both. 

The third question arises only in those cases in which the specimens 
have not been examined thoroughly by division and maceration. Fibrous 
union has sometimes been so close and firm that it has been thought to 

1 Philadelphia Med. Times, October 26, 1872, p. 49. 



FRACTURES OF THE NECK OF THE FEMUR. 499 

be bony. The technical significance of these doubtful ca&es is quite dis- 
tinct from their practical bearing, for the limb can be made as useful by 
close fibrous union as by bony union, and therefore, even if the latter is 
considered impossible to be obtained, the inference that immobilization 
is useless and treatment unnecessary is unjustifiable. 

The second question is the one that is most difficult to be answered; 
given a specimen with history of fracture and bony union, where did the 
line of fracture run? The answer to the question is made difficult by 
the extensive absorption of the neck and by uncertainty as to the original 
point of attachment of the capsule. My impression is that the import- 
ance of the doubt has been magnified by the preconceived opinion of 
many observers and writers, that union is practically impossible, an 
opinion which leads them to demand much more strict and definite proof 
than is ordinarily required in similar questions. The disappearance of 
the neck by crushing or absorption, or its impaction into the shaft brings 
the head close to the trochanters, and the changes wrought in the ap- 
pearance and. compactness of the tissue by the process of repair make it 
difficult to determine the relations and belongings of the parts. 

The question is not of sufficient general importance to make it desir- 
able to examine here the testimony for and against each alleged case. I 
quote the descriptions of five cases in illustration, two of which, the 
third and fifth, have not been quoted in the text books and discussions. 1 

Stanley's case. 2 A lad 18 years old fell from a cart, striking upon 
his right hip. He was unable to move the limb ; it was bent to a right 
angle with the pelvis, could not be extended, and abduction was difficult. 
There was eversion, no shortening, no crepitus. He died three months 
afterwards of smallpox. The capsule was thickened, the ligamentum 
teres uninjured; a line of fracture extended obliquely through the neck 
entirely within the capsule ; the neck was shortened, the head approxi- 
mated to the trochanter. The fractured surfaces were in close apposi- 
tion and united nearly in their whole extent by bone. Thejre was an 
irregular deposit of bone beneath the periosteum along the : Tine of the 
fracture. 

Swan's case. 3 Mrs. Powell, above 80 years of age, fell down Nov. 14, 

1 Foi> tlie convenience of those especially interested in the subject, I add the follow- 
ing references to the principal sources "of information concerning the cases and speci- 
mens : Med. Chirurg. Transactions, vols. xiii. and xviii. ; Sir Astley Cooper, Fracts. 
and Disloc. ; Dupuytren, Lecons Orales, vol. ii. p. 115 ; Malgaigne, Fractures, vol. i. 
p. 677 ; R. W. Smith, Fractures in the Vicinity of Joints, p. 52 ; Hamilton, Fracts. 
and Disloc. ; Grurlt, Knochenbriiche, vol. i. p. 307 ; Massey, in Am. Journal Med. Sci- 
ences, 1857, i. p. 299 ; Packard, in the same, 1867, ii. p. 377 ; March, in Trans. Med. 
Soc. of State of New York, 1858, p. 191 ; Johnson, in N. Y. Journal of Med. 1857, p. 
295 ; Geo. K. Smith, in Med. and Surg. Reporter, Phila., 1862, vol. vii. p. 244. 

The earliest recorded case with which I have met is one quoted by Earle (Practical 
Observations in Surgery, 1823, p. 97) from Christopher Henry Erndleus, Relatio Itine- 
ris Anglic, et Batav. p. 86, date not given, and as the case is not referred to by any 
later writer, I quote the description in full. " Talem fracturam his meis oculis vidi 
et manibus palpavi in cadavere fceminas nosocomei muliebris Amstelodamensis socice 
in qua tractu temporis, fractura ilia cervicis ossis femoris dextri per callum coaluerit 
iterum, foemina tamen exinde per omnem setatern ad mortem usque clauda. Callus 
pollicis latitudine sub ipso capite magno ossis femoris extabat, nulla autem in ligamentis ac 
tendinibus musculorum Icesio vel prozter naturalis constitutio erat." 

2 Med. Chir. Trans., vol. xviii. 1833, p. 256. 

3 Swan on Dis. of Nerves, p. 304, quoted by R. W. Smith, loc. cit., p. 59. 



500 



FRACTURES OF THE FEMUR. 



1824. Sir Astley Cooper, who saw her soon after, believed that there 
was a fracture of the neck of the femur, although there was no appreci- 
able shortening of the limb, and only a slight inclination of the toes out- 
ward, no crepitus. The patient died about five weeks afterwards. The 
fracture was found to have been entirely within the capsular ligament, 
and the greater part of it was firmly united. After section through the 
fractured part, a faint white line was perceived in one portion of the 
union, but the rest appeared to be entirely bone. 

Supposing the diagnosis in this case to have been correct, union in 
five weeks can be explained only on the supposition that the fracture 
was without displacement and without laceration of the periosteum. 

Gurlt 1 describes a specimen contained in the museum at Giessen (figs. 
266 and 267). "The fracture runs obliquely through the neck of the 
femur ; in front it is three-fourths of an inch from the base of the neck, 



266. 



Fig. 267. 





Pure intracapsular fracture of the neck of the 
femur. Bony union. (Gurlt.) 



Oblique section of the specimen shown 
in fig. 266. (Guilt.) 



posteriorly a little less. The head of the bone is displaced somewhat 
backward and downward, and is united by bone, although the line of 
fracture is still visible in places. 

Brulatour's case. 2 A man, 47 years old, was thrown from his horse ; he 
arose and walked a step or two, but the attempt caused great pain and 
he fell again. There was shortening of the limb, eversion, crepitation. 
Extension was kept up for two months. Three months after the accident 
he was able to walk with a cane, and subsequently recovered full use of 
the limb. He died nine months after the accident. 

The capsule was found a little thickened, the neck of the femur 
shortened, an irregular line surrounding it and showing the direction of 
the fracture, and a considerable bony deposit at the bottom of the head 
of the femur and at the external and posterior part. On section the 
line of union indicated by the callus was smooth and polished as ivory. 



1 Loc. eit., vol. i. p. 308. 

2 Med. Chir. Trans., vol. xiii., 1825, p 



i. 513. 



FRACTURES OF THE NECK OF THE FEMUR. 



501 



The line of callus denoted also that the bottom of the head of the femur 
had been broken at its superior and posterior part. 

Cushing's case. 1 A woman, 70 years old, fell upon her side while 
reaching to wind up a clock. There was no obvious displacement but 
the disability was such as to leave no doubt of the existence of a frac- 
ture. She was kept in bed for two and a half months with the knee 
flexed over two pillows, and then began to sit up with the leg extended. 
Crutches were used for six months, then a crutch and cane, and then 
for the last two and a half years she was able to go about the house un- 
aided ; there was no shortening and but little limping. During the 
first few weeks there was much pain at the seat of the injury and in the 
limb, which gradually became atrophied. She died about five years 
after the accident. 

The neck of the femur (fig. 268) is short and thick, the line of frac- 
ture corresponding nearly with the edge of the articular cartilage. The 
head of the bone has been depressed so that the neck is now nearly 
transverse ; the head is also bent obliquely backward and downward 
towards the lesser trochanter, and the shaft thus rotated outward. 
In front, the neck of the bone projects beyond the articular cartilage, 

while behind it is buried beneath it ; it is thus 
impacted posteriorly into the head, which in 
bending backward opens a fissure filled in 
front with an irregular bony callus. 

Prof. Bigelow thinks that the fracture when 
recent resembled that represented in fig. 264. 

Fiff. 269. 



Fis:. 268. 




Impacted intracapsular fracture. 
(Bigelow.) 




Fracture within the capsule. Close fibrous union. 



Other specimens and reported cases show that while complete failure 
of union or scanty fibrous union is the rule it is apparently due mainly 
to the mobility of the parts upon each other or their displacement. The 
specimens show that the head can preserve its vitality perfectly, that 



1 Bigelow, the Hip, p. 133. 



502 FRACTURES OF THE FEMUR. 

the fractured surfaces can become united by a firm fibrous bond (fig. 
269), or, failing that, that their tissue may become eburnated. The 
capsule usually thickens and sometimes becomes closely adherent to the 
periosteum lining the neck, and thus obliterates all the outer portion of 
the original cavity of the joint. This was the condition in two cases 
reported by Colles, 1 and there was actually a false joint between the 
fragments, the surface of the lower one being hollowed out to receive 
the upper. Sometimes the capsule ossifies in part. The two following 
cases are quoted to show the ability of the upper fragment to produce 
granulations and to illustrate close fibrous union without absorption of 
the neck. They are both taken from R. W. Smith, cases 59 and 58. 
See also his cases 11 and 16 for examples of eburnation. 

A man, fifty-two years old, was admitted to the City of Dublin Hos- 
pital with an intracapsular fracture of the neck of the femur, and died 
of bronchitis on the sixteenth day. Very little synovia was found in 
the hip-joint ; a layer of lymph covered the entire inner surface of the 
capsule, w T as closely adherent to it, and vascular ; at several points it 
adhered to the head and neck of the femur. 

The fracture w 7 as entirely within the capsule, passed in a tortuous 
direction downward and outward to the compact tissue at the under part 
of the neck, where it ran very obliquely downward and outward, thus 
leaving connected with the upper fragment in this situation a sharp 
wedge-shaped portion of the compact tissue of the bone, which over- 
lapped the lower fragment. The cervical ligament [periosteum] torn in 
front was perfect behind and below ; the surface of each fragment was 
highly vascular, and several shreds of lymph connected them ; in fact, 
a thin layer of lymph was eifused between the opposed surfaces of the 
fracture, on separating which it was drawn out into the thin and delicate 
bands above mentioned. The fracture in this case was caused by a fall 
directly on the most prominent external part of the trochanter major, 
and the patient walked a few yards after the receipt of the injury. The 
foot was everted and the limb shortened exactly half an inch. 

A woman, eighty years old, fell upon her left hip while walking across 
her room and w T as unable to rise. She was seen an hour afterwards, 
complained of severe pain in the region- of the joint, and could not move 
the limb which was slightly inverted, and any attempt to evert it caused 
great pain. A fracture of the other leg that had united with much de 
formity made it impossible to recognize shortening if it was present. 
She died eight weeks afterwards, having regained some control over the 
limb, which remained inverted. 

The fracture was close to the head of the bone above, passed thence 
downward and inward, leaving a portion about half an inch in length of 
the under part of the neck attached to the head. The head was dis- 
placed downward, overlapping the' neck below and behind, and being 
overlapped by it above and in front (see fiz. 265). There was thus a 
mutual impaction of the two fragments, and they were further main- 
tained in contact by a dense, fibrous tissue, which adhered closely to the 
broken surfaces. 

1 Dublin Hosp. Reports, vol. ii. p. 334. 



FRACTURES OF THE NECK OF THE FEMUR. 503 

In view of the closeness of the fibrous union shown in some specimens, 
of the occasional usefulness of the limb after fracture, and of the great 
uncertainty of the diagnosis in many cases, an uncertainty that is rec- 
ognized by all surgeons, and abundantly testified to by them, the prac- 
tical side of the question of the possibility of bony union after fracture 
of the narrow part of the neck, and entirely within the capsule, is not 
very important, for the treatment, or rather its duration, will depend 
mainly upon the patient's strength and general condition, and the prog- 
nosis will always be guarded. 

There is, however, another side to the question, an interest in which 
is legitimate, even if apparently without practical value. Even if we 
disregard all existing specimens of alleged bony union, the possibility of 
such union must, I think, be admitted, because of the demonstrated fact 
that the head preserves its vitality, and has shown its ability to produce 
granulations and bone ; the former proved by the examples of fibrous 
union, the latter by eburnation or condensation of its spongy tissue. 
More than this, it has been shown even that pieces of bone completely 
detached may regain complete vascular connection and bony union with 
the piece from which they have been broken, and, therefore, it is proper 
to assert that it is theoretically possible for the completely detached 
head of the femur to regain connection with the neck, much more so for 
one that has preserved more or less of its fibrous connection. Fibrous 
union after fracture is demonstrated by several specimens ; ossification 
is merely the ultimate step in the evolution of the granulations arising 
from bone, and it has been shown in the study of failure of union, of 
pseudarthrosis, that the arrest of the process is commonly due to lack of 
immobilization, defective contact, or constitutional peculiarities of which 
old age is not one. Prolonged complete immobilization of a fracture of 
the neck of the femur is practically impossible, accurate coaptation of the 
fractured surfaces is a matter of chance, and the reason of the habitual 
failure to get bony union is to be found in the inability of the surgeon 
to meet the two principal indications of treatment, coaptation and im- 
mobilization, not in any inability of the tissues themselves to do the work 
required of them. The absence of the enveloping mass of soft parts 
which are found about other fractures, and which contribute so elficiently 
to their repair, constitutes an additional difficulty in this case, but does 
not make repair impossible. The history of impacted fractures, or frac- 
tures with crushing, shows that spongy bone is capable of repairing its 
own injuries without aid from the periosteum or the overlying soft 
parts. In the two cases quoted at the beginning of this section, Mayor's 
and Stanley's, in which the periosteum remained entire and there was 
no displacement, the presumption is entirely in favor of the possibility 
of repair, and it is in such cases that the diagnosis would subsequently 
be most doubtful, as in Swan's case. Tne probability of repair is greatest 
under such circumstances, and diminishes as the displacement increases. 

The common result of this fracture is permanent disability, more or 
less complete. The patient is sometimes bedridden because of the pain 
provoked by motion and of the general feebleness which makes it impos- 
sible for her to get about with crutches ; or limited use of the limb may 
be possible with the aid of a cane, or its place may be supplied by 



504 FRACTURES OF THE FEMUR. 

crutches. The foot remains everted, the limb shortened. In excep- 
tional cases the patient may have very good use of the limb, even when 
union has failed entirely, as in the following case reported by Gosselin. 1 

A woman, 66 years old, received a fracture of the thigh which was 
treated simply by rest in bed for three weeks. After this time she 
walked with crutches, and left the hospital seven weeks after admission, 
using only a cane, and able to walk for fifteen minutes at a time ; the 
improvement continued and she became able to walk half an hour at a 
time, still with the aid of a cane, and was considered, by Gosselin, an 
example of good consolidation after a fracture, the exact position of 
which, whether intra- or extra-capsular, he had not felt able to determine 
positively. Seven or eight months later she returned to the hospital 
and died. The autopsy showed an intracapsular fracture, not united. 
The fragments were held together only by a few strips of periosteum, 
and moved upon each other, forming a pseudarthrosis resembling an 
arthrodial joint. 

The diagnosis and treatment will be considered subsequently in con- 
nection with those of fracture at the base of the neck. There are no 
signs absolutely distinctive of fracture at the narrow part of the neck 
in contradistinction from those of the base. The question turns usually 
upon the degree of certain symptoms, and upon probabilities, both of 
which are untrustworthy as aids in diagnosis. 

{b) Fractures at the Base of the Neck (Extracapsular fractures). — The 
line of fracture follows ordinarily the junction of the neck and shaft 
quite closely, that is, it coincides with the spiral line in front and the 
inter-trochanteric line behind as they pass between the great and lesser 
trochanters. It may extend downward and detach the lesser trochanter 
from the shaft, leaving it attached to the neck, or go even lower and 
separate a part of the shaft. At its upper part it may deflect to either 
side, crossing the outer part of the neck or traversing the upper part of 
the great trochanter. 

In the majority of cases other lines of fracture traverse one or both 
trochanters, splitting off one or two pieces, usually from the posterior 
surface of the great trochanter, or comminuting it completely. Mal- 
gaigne thought simple fracture, division into only two fragments, was 
exceedingly rare ; the only case of which he knew, excluding two in 
which the fracture crossed the trochanter horizontally, was one described 
by R. W. Smith (loc. cit., Case 34), and as even in this two fragments 
are broken off the trochanter behind it is evident that he believed con- 
siderable comminution to be the rule. Hamilton refers to two simi- 
lar specimens, one in Dr. Mutter's, the other in Dr. Neill's collection ; 
and in one of the six autopsies to which I referred above there was no 
splintering, and in another the fracture was almost identical with the one 
quoted by Malgaigne from Smith. The first of these two specimens was 
presented to the New York Pathological Society, in January or Feb- 
ruary, lbT9. 

The common fracture is that in which the neck is bent backward with 
crushing of the posterior part or penetration of the neck into the tro- 

1 Clinique Chirurgicale, vol. i. p. 360. 



FRACTURES OF THE NECK OF THE FEMUR. 505 

chanter. Prof. Bigelow 1 directed especial attention to this bending back- 
ward and impaction (fig. 270) as the important features of the most 
common form of fracture in this region, the symptoms of which are pain 
and tenderness, disability, shortening and eversion, however slight, 

Fig. 270. 




Impacted fracture at the base of the cervix femoris, with bending of the head backward. (Bigelow.) 

absence of crepitus, and rotation of the trochanter about the head of the 
bone as a centre, and he described the displacement as a rotation of the 
head and neck backward and downward upon the portion of the anterior 
wall corresponding to the spiral line uniting the trochanters as upon a 
hinge. This displacement accounts for the eversion and slight short- 
ening. 

A certain amount of misapprehension has resulted from the use of the 
word i?npaction. Impaction, in the sense of penetration and fixation, is, 
I think, comparatively uncommon ; while crushing, with or without pene- 
tration or much splitting of the trochanter, is the rule. The penetration 
or crushing may be limited to the posterior part (this, as has been said, 
is the most common condition), or the neck may turn upon its upper por- 
tion, making that the hinge, and sink its anterior, posterior, and lower 
walls into the substance of the trochanter (fig. 271), or the neck may 



1 The Hip, p. 118, and Boston Med. and Surg. Journal, vol. 92, 1875, pp. 1 and 29. 



506 



FRACTURES OF THE FEMUR 



be driven bodily into the trochanter without changing its direction, and 
may even penetrate to the opposite wall. In exceptional cases the lower 
fragment may penetrate the upper one. 



Fig. 271. 



Fie. 272. 





Impacted fracture of the neck of the femui 
without splintering. Vertical section. 



Repair after fracture of the neck of the femur. 
(Lossen.) 



Fig. 273. 



Fig. 274. 





Comminuted fracture of the neck of the 
femur. (Bryant.) 



Fracture of the neck of the femur with splitting 
of the great trochanter. 



The splitting of the trochanter may be limited to one or two pieces 
broken off its posterior border (fig. 274), or it may be very general 



FRACTURES OF THE NECK OF THE FEMUR. 



507 



(fig. 275). The extent of the splitting 
seems to be independent of the force that 
caused the fracture, extensive comminution 
being sometimes produced by a simple fall 
while walking, as in fig. 276, which is drawn 
from one of my own specimens. 

In a few cases the angular displacement 
of the neck has been in the opposite direc- 
tion, so that the limb has been rotated in- 
ward instead of outward. R. W. Smith 
(loc. cit., p. 128) describes one such speci- 
men, and Bigelow (loc. cit., p. 128) an- 
other. In a number of cases inversion has 
existed when the fragments were not inter- 
locked. 

Partial, incomplete fracture was asserted 
by Adams 1 to be common. He thought that 
a fall upon the trochanter tended to enlarge 
the inferior angle between the neck and the 
shaft, to bring the two more nearly into line, 



Via: 275. 




Comminuted fracture of 
the femur. 



Fig. 276. 



Fi°-. 277. 






Comminuted fracture of the neck of the femur. 
Anterior aspect. 

and thus caused a fracture or crack of 
the lower wall of the neck, and that 
the fracture became complete in con- 
sequence of attempts to use the limb or 
of the contraction of the muscles. This 

theory, which seems to have made some impression at the time, has 
proved incorrect. The only known instances of partial fracture have 
been quoted in the preceding section, page 495. 

The common symptoms are inability to move the limb, local pain, 
eversion and shortening more or less marked, and crepitus sometimes 



Exuberant callus after fracture of the neck 
of the femur. (Smith.) 



» Dublin Med. Journal, vol. 6, 1835, p. 220. 



508 FRACTURES OF THE FEMUR. 

to be felt on rotation or extension. They will be described in detail 
in a subsequent section, as will also the prognosis and treatment. 

Repair. — In most cases bony union takes place, and indeed the pro- 
duction of bone is often excessive (fig. 277) and interferes with the sub- 
sequent use of the limb. In one of Smith's cases (loc. cit., Case 51), 
fracture with penetration, the fragments were movable upon each other 
but could not be separated because of the new bone which had grown 
from the outer fragment and enveloped or interlocked the end of the 
inner one. The average period of time thought to be sufficient for con- 
solidation, has been estimated at from forty to fifty days. 

Symptoms of Fracture of the Neck of the 'Femur. — The symp- 
toms of the fracture and the signs upon which the diagnosis must be made 
include not only the usual objective and subjective symptoms of fracture 
but also the history of the case, the nature and especially the slight de- 
gree of the violence which so often characterizes this injury. 

Interference ivith Function. — As a rule the patient is unable to use 
the limb, and he is not merely unable to bear his weight upon it but he 
cannot even move it in bed. Exceptions to this have been already men- 
tioned, and it is not particularly uncommon to see patients who, while 
lying on the back, can slowly flex the thigh upon the pelvis either by its 
muscles alone or with the aid of the hands, but they cannot raise the 
foot from the bed, the knee bends at the same time and the foot is 
drawn up towards the body. Most authors have mentioned cases in 
which the patients have walked for longer or shorter distances imme- 
diately after the injury, and in which the existence of a fracture has sub- 
sequently become very clear. Thus, Sabatier 1 describes two, Desault 2 is 
said to have seen several and to have published one, and Boyer 3 de- 
scribes one in which the patient walked with the aid of a cane for seve- 
ral days. This is very exceptional, and it is sufficient to bear the possi- 
bility in mind to avoid the error of inferring that a fracture cannot be 
present because the patient is or has been able to use the limb. 

The opposite error, that of supposing a fracture to exist because the 
limb has been disabled by a fall, can be easily made, because a simple 
contusion may cause eversion of the limb as well as ecchymosis and 
swelling, and in some cases fracture causes no other symptoms than 
these. Observatiou of the case for a few days will make the diagnosis 
clear. 

Pain is always present. It is usually slight, or even absent, when 
the patient is at rest, but is readily excited by even slight communicated 
or voluntary movements. It is referred sometimes to the region of the 
trochanter, sometimes to the groin or inner and upper portion of the 
thigh. Sometimes pressure with the end of the finger detects a particu- 
larly sensitive point in the line of the neck in front just outside the great 
vessels. 

The posture and appearance of the limb are so characteristic that it is 
sometimes almost safe to make the diagnosis by simple inspection. As 

1 Mem. de la Societe Royale de Chirurgie, vol. iv., 1768, p. 638-9. 

2 (Euvres Chirurgicales, vol. i. p. 223. 

3 Malad. Cliirurg., 4th ed., vol. iii. p. 261. 



FRACTURES OF THE NECK OF THE FEMUR. 509 

the patient lies upon his back the affected limb appears shorter than the 
other, everted, and slightly flexed and abducted, and conveys an impres- 
sion of helplessness that is often very striking. The upper portion of the 
thigh is swollen in front and on the outer side, and ecchymoses appear 
after a day or two. 

Eversion may be so marked that the foot rests entirely upon its outer 
border as the patient lies upon the back. In other cases it is so slight 
that, as Prof. Bigelow has pointed out, it is best recognized by compar- 
ing the extent to which the two feet can be inverted. 

In exceptional cases the limb is inverted; 1 it is either found so on the 
first examination 2 or it becomes so after a day or two ; Desault estimated 
the frequency of this symptom at one-fifth of all cases ; in 60 cases 
tabulated by Smith eversion is noted 33 times, and inversion 7 times, in 
1 it is said there was no rotation to either side, and in the remaining 19 
the symptom is not mentioned. 

The cause of the eversion is probably almost always mechanical ; it is 
simply the effect of gravity acting upon the limb under changed condi- 
tions of support. It is favored by angular displacement of the neck of 
the bone when accompanied by impaction and fixation. On the other 
hand, eversion has been observed in cases of simple contusion, and in 
others of fracture in which there was no displacement of the fragments, 
no rupture of the periosteum even, and consequently no loss of support. 
When one lies upon his back a distinct, although slight, effort is required 
to keep the toes upright ; the natural tendency of the limb is towards 
eversion, particularly if the knee is slightly flexed, and this tendency 
which is increased by anything that diminishes the activity of the mus- 
cles must be taken into account in those obscure cases where the diag- 
nosis lies between a contusion and a fracture. The claim that eversion 
is due to contraction of the external rotators cannot be substantiated ; 
the single fact that eversion becomes, if possible, even more marked after 
death is sufficient to show r its incorrectness. 

The cause of inversion is not so clear. Smith attributes it to the 
position of the fragments relative to each other, and says that in all the 
cases of inversion which he was able to examine post mortem he found 
the lower fragment in front of the upper one. This, however, does not 

1 According to Sabatier and Louis (Mem. de la Societe de Chirurgie, vol. iv. 1768, p. 
632 and 653) Ambroise Pare was the first to recognize the possibility of fracture of the 
neck of the femur, and it is singular that in his first case, supposed for two days to be 
a dislocation, the limb was inverted. The patient was an old woman and the fracture 
was recognized by the crepitation produced by attempts to reduce the supposed. dislo- 
cation. Sabatier and Louis looked upon the statement that the limb was inverted as 
an error of observation or as meaning only that the foot was held nearer the other leg 
than the knee was, or as an error of the copyist. On the strength of this statement 
by Pare inward rotation of the limb seems to have been considered a classical symp- 
tom of fracture of the neck of the femur for more than a century. 

2 While these pages were going through the press I received from Prof. W. J. Conk- 
lin, of Dayton, Ohio, an interesting account of a case observed by him and published 
in the Columbus Medical Journal, November, 1882, in which marked inversion was 
present and persisted until the patient's death, four weeks after the accident. The 
patient was a woman 84 years old, and the fracture was caused by a fall from the stool 
backward upon the trochanter. The post-mortem examination showed an impacted 
fracture at the base of the cervix femoris. 



510 FRACTURES OF THE FEMUR. 

always explain the symptom when the fracture is of the narrow part 
of the neck, intracapsular, as in Stanley's case quoted above (p. 497), 
although it may do so in some, as in the case observed by Goyrand 1 
where the neck had slipped behind the head and was fixed between it 
and the capsule. 

The diagnostic value of the posture of the limb, as regards eversion 
or inversion, is not very great, for inversion is a symptom that needs, as 
it were, to be explained away, and eversion may be due to a simple con- 
tusion. It is important, therefore, that the exact nature and extent of 
the rotation should be determined, and the sources of error are that an 
eversion which is only apparent may be thought to be real, and that it 
may be purely passive and accidental, the limb taking and keeping the 
inverted position quite as readily. 

In order to estimate the degree and persistence of the eversion the 
patient should be placed flat upon his back with the thigh and leg ex- 
tended. A comparison with the other foot will then show the degree of 
the eversion, and gentle efforts to rotate the limb will show to what ex- 
tent and in what manner the movements are restricted. 

Shortening of the limb is produced either by alteration of the angle 
between the shaft and the neck or by overriding, and may vary in extent 
from a small fraction of an inch to two, three, or even four inches. It 
may be present and at its maximum immediately after the accident, or it 
may be absent at first and appear gradually or suddenly after the lapse 
of a few hours or days, or may increase gradually, or suddenly. It is 
usually held that when the fracture is of the narrow part of the neck 
(intracapsular) the shortening is absent or slight at first, increases more 
or less gradually, and never exceeds one and a quarter inches, and 
gradual increase in the amount of shortening is claimed by some to be 
pathognomonic of this variety of fracture. These statements are true 
only as an expression of the average condition; in exceptional intra- 
capsular cases the shortening may exceed this amount, and in fractures 
at the base of the neck it may increase gradually in the same manner. 

In measuring the limbs care must be taken to have them form the same 
angle with the pelvis, that each is in the same position of extension and 
abduction. If the injured limb cannot be brought parallel to the median 
line of the body the other must be abducted to the same degree. To 
insure this symmetry it is well to stretch a cord downward at right 
angles to and from the centre of another cord stretched between the tw T o 
anterior superior iliac spines, and then to place the ankles at equa] dis- 
tances from it and as near to it as is convenient. The measurements are 
usually made between the anterior superior spine of the ilium and the 
external malleolus. 

Another method of recognizing shortening and of measuring its extent 
is one recommended by Mr. Bryant, a modification of the former one of 
measuring the distance between the top of the trochanter and the crest 
of the ilium. The original method contained a possible source of error 
in the occasional displacement of the trochanter backwards which brings 
it into line with a higher part of the curved crest of the ilium, and thus 

1 Diet. Encyclopedique, Art. Cuisse, p. 239. 



FRACTURES OF THE XECK OF THE FEMUR. 



511 



the elevation of the trochanter would not necessarily be accompanied by 
a diminution of the distance measured. Therefore, instead of measur- 
ing to the crest of the ilium, Mr. Bryant measures to the transverse 
vertical plane passing through the anterior superior spinous processes. 
Thus, in figure 278 a c represents the vertical plane passing through 




Bryant's ilio femoral triangle, for diagnosis of fracture of the neck of the femur. 



\^C 



these processes, and b is the top of the great trochanter. In fractur 
of the neck with shortening b is brought nearer to c. The same car 
must be taken to have the limbs in 

symmetrical positions, and I have p^. 279. 

found it convenient to mark the ver- 
tical plane by placing a small stick 
or pencil upright beside the pelvis 
and in line with the processes and 
then to measure the distance be- 
tween it and the trochanter. 

Another, but less accurate method 
of recognizing the elevation of the 
trochanter is to find its position with 
reference to " Nelaton's line," the 
line taken by a cord stretched be- 
tween the tuberosity of the ischium 
and the anterior superior spine of 
the ilium. Under normal conditions 
this line crosses the top of the tro- 
chanter when the thigh is slightly 
flexed on the pelvis. 

Attention has been called by Dr. 
Allis to an effect of this shortening 
which can be easily recognized ; the 
relaxation of the fascia lata be- 
tween the ilium and the trochanter 
(fig. 279). 

The shortening can sometimes be 
overcome,, entirely or in great part, 
by gentle traction upon the limb 
combined with enough rotation in- 
ward to correct such e version as 




r^C 



Method of recognizing the relaxation of the 
fascia lata after fracture of the neck of the 
femur. 



512 FRACTURES OF THE FEMUR. 

may exist. I think the dread of separating impacted fragments by ex- 
tension has been somewhat exaggerated. The penetration is trans- 
verse, and longitudinal traction that is not violent enough to cause much 
pain cannot do more than change the angle at the junction of the neck 
and shaft, it does not separate the fragments from each other. Rotatory 
movements communicated to the limb are more likely to do harm, as is also 
such lack of support as will allow the eversion and shortening to be increased. 

Crepitation is occasionally perceived during the manipulation of the 
limb, either in extension or rotation, or on pressure behind the trochanter, 
but it is far from being a constant sign, either because of impaction or 
of splintering that leaves the pieces too loosely connected to produce it. 
The sign is one that should not be repeatedly sought for ; in the cases 
that are really obscure it is highly improbable that it can be obtained, 
and in the others it is not needed. It was long ago noticed by Sabatier 
that those patients who had been persistently handled at the first examina- 
tion showed the most severe inflammatory reaction and furnished most of 
the fatal cases. 

Among other signs which may be present are enlargement of the great 
trochanter when it has been split or comminuted, change in its distance 
from the median line of the body, change in the centre of rotation of the 
limb, and change in the depressibility of the outer portion of Scarpa's 
space. 

The enlargement of the trochanter in consequence of its having been 
split by the outer end of the neck is sometimes very marked and easily 
recognized when the soft parts are not swollen by grasping it between 
the thumb and fingers. In two cases reported by Stanley 1 a portion of 
the trochanter was broken off behind and drawn backward towards the 
sciatic notch, suggesting by its position and shape' that it might be the 
dislocated head of the femur. 

The distance between the outer face of the trochanter and the median 
line of the body may be increased or diminished, but the change is 
seldom very marked and is difficult of accurate determination. It is 
easier to prove that it ought to exist on theoretical grounds, than to re- 
cognize it if actually present. If the neck is driven into the trochanter 
the distance of the trochanter from the cotyloid cavity is diminished by 
the amount of the penetration ; if, on the other hand, there is no pene- 
tration or crushing and the displacement is an angular one in the vertical 
plane, the bone being pushed up until the angle at the junction of the 
neck and shaft becomes a right angle, the distance is increased because 
the neck then stands directly out from the body instead of being inclined 
downward ; and thirdly, in combinations of penetration and this angular 
displacement the two changes may neutralize each other in whole or in part. 

In firmly impacted cases with but little shortening or eversion the 
trochanter sometimes appears exceptionally prominent, and, according to 
R. W. Smith, this prominence of the bone becomes very marked when 
the patient is supported in the upright position, but ordinarily the region 
is flattened and the trochanter appears to be sunken, displaced inward 
and backward. 

1 Med. Chirurg. Transactions, vol. xiii. p. 504. 



FRACTURES OF THE NECK OF THE FEMUR. 513 

Rotation of the trochanter upon a shorter radius than usual is another 
symptom found in the text-books but not at the bedside. Theoretically, 
if the lever upon which rotation is made is broken a new centre is formed 
at the seat of fracture or the radius is shortened by impaction. Nothing 
could be simpler or more accurate in theory, but in practice it is beset 
with difficulties that make it worthless as a sign, for it is recognizable 
only in cases where the diagnosis cannot be in doubt. 

It is practically impossible to tell by pressing the finger against the 
outer face of the trochanter whether it rotates upon a long or a short 
axis, for the range of permissible motion is too limited to make it possi- 
ble to recognize the sharpness of its curve. In cases of fracture with 
crushing of the neck and when the shaft lies unconnected with the re- 
mainder of the neck and the head, rotation of the limb takes place about 
the longitudinal axis of the femur, the centre of motion is within the 
shaft, not outside of it in the cotyloid cavity, and this can sometimes be 
recognized by pressing the finger against the posterior face of the tro- 
chanter and rotating the limb gently. Instead of rising from the finger 
the bone may be felt to slide over it. 

The change in the depressibility of Scarpa's space is signalized by 
Hennequin 1 as a valuable diagnostic symptom. Under normal conditions 
the fingers can be pressed deeply into the limb in the outer portion of 
Scarpa's space, but when the neck of the femur is broken this depressi- 
bility is reduced in varying degrees, apparently by the angular displace- 
ment (with the apex directed forward) which takes place so commonly 
at the junction of the neck and shaft. The same condition was described 
by Laugier 2 as a sort of bony tumor to be felt on the outer side of the 
great vessels an inch or two below Poupart's ligament, slight pressure 
upon which was painful. 

Diagnosis. — In most cases the existence of a fracture of the neck of 
the femur can be readily determined and sometimes its variety can also 
be easily recognized, but in others the main character of the injury is 
very obscure, and in a large proportion of cases it is simply impossible 
to say whether the fracture is intracapsular or extracapsular, of the 
narrow part of the neck or of the base of the neck. This difficulty is 
recognized by all practical surgeons and finds expression in some sur- 
gical works, although the text-books still preserve the distinction between 
the two forms and lay down rules for their recognition. Grosselin 3 says 
" a rigorous diagnosis between extra- and intra-capsular fractures is both 
impossible and useless." Mr. Bryant 4 says " the old division of intra. 
and extra-capsular fractures is as unscientific as it is impracticable ;" and 
Agnew 5 " to recognize clearly a fracture through the neck of the femur, 
or to assert with positiveness that such a fracture is present is often a 
matter of no small difficulty, and occasionally one of impossibility ;" and 
Hamilton 6 " the diagnosis between these two varieties of fracture is often 
impossible during the life of the patient." 

1 Des Fractures du Femur, p. 700. 

2 Diet. Encyclopedique, art. Cuisse, p. 507. 

3 Clinique de la Charite, vol. i. p. 346. 4 Loc. cit., p. 841. 
5 Loc. cit., vol. i. p. 941. 5 Loc. cit., p. 425. 

33 



514 FRACTURES OF THE FEMUR. 

When the symptoms described above are clearly marked, when there 
is the history of a fall followed by complete loss of power in the limb, 
with shortening, eversion, crepitation, pain at the hip, and elevation of 
the trochanter, there can, of course, be no doubt, — the neck of the 
femur is broken. But when the limb is not entirely powerless, when 
the shortening and eversion are slight, perhaps even doubtful, when 
crepitation is not felt, when, in short, there is no single positive sign, 
the only course is to withhold the judgment, and wait for time to make 
the diagnosis clear. If the injury is only a contusion the recovery will 
be prompt and not marred by lameness ; if it is a fracture the more posi- 
tive signs may appear as the tenderness and swelling subside, shorten- 
ing and eversion will probably become evident, the patient will be unable 
to bear his weight upon the limb for several weeks, and he will probably 
walk always with a limp. 

The examination should be directed first to the history of the case, 
then to the functions of the limb, then to its attitude and length, the' 
condition and height of the trochanter, and the depressibility of Scarpa's 
space. If any doubt then remains the limb may be gently rotated, in 
order to judge of the degree of eversion and of its mobility, to elicit 
crepitation, and, if desired, to estimate the radius of rotation. 

A possible source of error in the existence of a former fracture, or of 
a deforming or dry arthritis, to which a fresh contusion has just been 
superadded, must be borne in mind when the history of the case is 
inquired into. 

Dislocation is eliminated in case of eversion by noting the absence of 
the head of the femur from the pubic region. The only dislocation that 
is characterized by eversion and shortening is dislocation upon the pubes, 
and in it the head of the bone can be very readily felt. The exclusion 
of dislocation backward upon the ilium in case of fracture with inver- 
sion of the limb is more difficult. In dislocation the limb is more fixed, 
it is adducted and flexed, the head of the femur can be felt posteriorly, 
and its absence from the cotyloid cavity may be recognized by palpation. 
In fracture the inversion may give place to eversion after traction upon 
the limb. 

Fracture of the acetabulum with penetration of the head of the femur 
into the pelvis has usually been mistaken for fracture of the neck of the 
femur. The means of diagnosis has been mentioned in the preceding 
chapter. The mistake is comparatively unimportant, since the treatment 
is the same in the two cases. 

With reference to the differential diagnosis between intracapsular and 
extracapsular fractures, it can only be said that some of the latter can 
be positively recognized, as, for example, when the trochanter is commi- 
nuted, or the immediate shortening is very great, or when the bony mass 
can be felt plainly in Scarpa's space. An opinion may be formed in 
others according to the degree of the violence, the age of the patient, 
the disability, and the extent of the shortening, but it can never express 
more than a probability. It may be reasonably expected that after the 
lapse of ten or fifteen days the swelling will have so far diminished that 
a close examination of the trochanteric region can be made, and then 
the differential diagnosis may be possible, because in fractures at the base 



FRACTURES OF THE NECK OF THE FEMUR. 515 

of the neck this region becomes enlarged and hardened by the formation 
of an external callus and the infiltration of the soft parts, while if the 
fracture is within the capsule this change does not take place. 

Prognosis. — In this must be considered the immediate danger to the 
life of the patient created by the accident, and the remoter influence 
upon the functions of the limb. Of the 60 cases collected by R. W. 
Smith 26 terminated fatally within the first month and 1 within the 
second month. It must not be thought that these figures represent the 
average mortality of the injury, for his collection is only of cases that 
had furnished specimens, but they will serve to call attention to the actual 
danger that does exist, and to the probability that death will be caused 
promptly if at all. 

The promptly fatal cases present two principal forms ; in one the pri- 
mary inflammatory reaction is sharp, a high fever sets in, the patient 
becomes delirious and dies within a few days, or pneumonia is developed 
soon after the accident and proves fatal. In the other form the patient's 
strength fails rapidly without much inflammatory reaction from the injury, 
and he dies cachectic, usually with an intercurrent pneumonia. It is 
possible that fat embolism, especially of the lungs, may be an important 
factor in producing this result. In other cases death follows an attack 
of traumatic delirium or an intercurrent bronchitis, or is the apparent 
result of marasmus due to prolonged confinement to the bed and constant 
pain. 

The injurious effect of confinement to the bed and of pain has been 
clearly demonstrated by the diminution of mortality that has followed 
the abandonment of treatment by inelastic extension and by strict and 
prolonged confinement to one position. Gosselin has called especial 
attention to this fact, and attributes the change in treatment to the in- 
fluence of the opinion that union was not to be expected after intra- 
capsular fracture, and that, therefore, it was useless to make extension, 
and to keep the patient in bed after the second or third week. He adds 
that in thirty years of hospital practice, 1840 to 1870, he had seen only 
one case of death within a fortnight after the accident. The influence 
of age upon the prognosis is very well marked, the older the patient the 
greater the probability of a fatal termination within a few weeks or 
months, and the greater also, it is believed, the probability that the frac- 
ture is intracapsular, and the disability consequently greater and more 
permanent. 

The inflammatory reaction is due in part to the arthritis set up by the 
injury, and this arthritis increases not only the immediate danger to life 
but also the subsequent disability in case of survival by the changes 
which it effects in the joint. This latter is always to be anticipated in 
a greater or less degree. The patient should be informed that even if 
union follows and the limb becomes useful, it will remain shortened and 
everted, and that the joint may long be stiff and painful. In fractures 
at the base of the neck, with or without impaction or comminution, union 
usually takes place promptly, even in advanced age, and the limb may 
become very useful, as in the following case. 

A woman who said she was " going on 80 years old," and who looked 
as if she was at least TO years old, an inmate of the Almshouse, was 



516 



FRACTURES OF THE FEMUR. 



pushed down by another woman in May, 1878, and broke the neck of 
the left femur. I found eversion, shortening of 1 J inches, and an ex- 
tensive ecchymosis covering the upper anterior, outer, and posterior 
portion of the thigh. The only treatment was rest in bed with the limb 
steadied and supported by cushions. She was not transferred to the 
hospital ward, and I soon lost sight of her. The following autumn I 
recognized her walking about the grounds with the aid only of a cane, 
and in the following February, I went to her ward and asked for her. 
She came walking forward briskly but with a marked limp. There was 
still marked eversion, and the same shortening ; the trochanter rose 
more than an inch above Nelaton's line and was not enlarged. There 
was no complaint of pain. 

What the proportion of useful limbs after fracture is, I cannot say ; 
Mr. Bryant 1 " says that of thirty consecutive cases averaging 74 years 
in age treated by him in Guy's Hospital, all were discharged with useful 
limbs." So far as my observation goes this result is far better than 
that usually obtained in hospital or private practice. 

Fig. 280. 




Ununited fracture of the neck of the femur, showing the hypertrophied outer fasciculus of the 
Y-ligainent supporting the weight of.the body in walking. (Bigelow.) 

In the more unfavorable cases, especially those of fracture within the 
joint and without union, the patient may remain completely bedridden 
or able only to change from the bed to a chair, or to take a few steps 



1 Lancet, 1880, i. p. 160. 



FRACTURES OF THE NECK OF THE FEMUR, 



517 



with the aid of a crutch or a nurse. Pain is common and the limb be- 
comes much atrophied. 

Failure of union after fracture within the joint does not necessarily 
cause complete disability. An instance of recovery with pseudarthrosis 
and good use of the limb has been quoted above from G-osselin. Figures 
280 and 281 are taken from one of Prof. Bigelow's specimens, and show 

Fig. 281. 







The same, seen from behind, showing the tense obturator tendon and the hypertrophied inferior 

gemellus. (Bigelow.) 

how the weight of the body can be supported by the anterior fasciculus 
of the Y-ligament in front of the femur, and the obturator internus behind 
after ununited fracture of the neck. 

Treatment. — The attainment of the ideal object of treatment, restora- 
tion of form and function, is not to be expected ; the small size of the 
upper fragment, the destruction of tissue by crushing, and the permanent 
change of the relations of the parts by impaction prevent the restoration 
of form, while the proximity or the involvement of the joint, combined as 
; t usually is with advanced age, insures limitation of the functions even 
after complete consolidation. 

The extent also to which attempts to reduce the displacement may be 
carried with propriety is limited. The same reasons which make it un- 
desirable in many cases to attempt to carry the diagnosis beyond the 
recognition of the simple fact that there is fracture of the neck of the 
bone forbid attempts to overcome shortening and eversion. In view of 
the age of the patient, the severity of the injury, the probability of the 



518 FRACTURES OF THE FEMUR. 

limitation of function in any case, the principal aim in treatment should 
be to keep the inflammatory reaction within the narrowest limits and to 
secure union at the earliest possible moment even if in a faulty position. 
The disability due to displacement may easily be less and of less im- 
portance than that due to a severe and prolonged arthritis excited or 
increased by the measures employed to overcome the displacement. 
Furthermore, in many cases the measures are not likely to be efficient. 
In fracture with impaction no traction that can be safely borne by the 
patient is likely to be sufficient to overcome the shortening, and in the 
common form of fracture, fracture at the base of the neck with crushing 
posteriorly and angular displacement in the direction of outward rota- 
tion of the limb, the eversion cannot be corrected without forcible 
manipulation, because when the inversion that is intended to correct it is 
kept within proper limits the motion takes place in the joint and not at 
the seat of the fracture, and the angular displacement, therefore, per- 
sists. And if the effort should succeed, if the angular displacement 
should be overcome, its probable effect would be to open a gap behind 
corresponding to the tissue that had been crushed, which would have to 
be filled by granulation, and which would certainly delay and perhaps 
prevent consolidation. 

The treatment must be directed mainly to immobilize the limb, and 
the extension that is made should be with the view to aid immobilization 
and to prevent additional shortening rather than to overcome such short- 
ening as may exisc, and this immobilization and extension should be 
kept up until consolidation has been obtained, in fractures at the base, 
and until the character of the fracture, when within the joint, has be- 
come evident, and failure of union certain, or until the condition of the 
patient renders removal from bed and change of position absolutely 
necessary. The first consideration is to keep the patient alive, the 
second to obtain union, the third to get union in a good position. 

It is not difficult to meet the indications, or, rather, simple measures 
will meet them sufficiently well. Prof. Bigelow says that he has ob- 
tained as good results, even in bad cases, from a fiat bed with a mode- 
rate weight attached to the limb for extension, and a broad band about 
the hips to steady the parts, and a cushion under the broken limb to 
prevent its eversion as from more complicated apparatus, and most sur- 
geons have probably had a similar experience. The simplest treatment 
is to make extension by weight by means of strips of adhesive plaster 
attached to the limb in the manner described in Chapter VIII., and to 
prevent eversion either by Yolkmann's sliding foot rest (p. 182), or a 
long side splint as after fracture of the shaft, or by pads or cushions. 
The bed should be firm, not soft or springy. 

Dr. Hamilton uses extension by weight and his long side splint. Mr. 
Bryant, whose remarkable series of thirty consecutive cases averaging 
74 years of age discharged with useful limbs has been mentioned, uses 
the double splint bracketed at the points corresponding to the trochan- 
ters (page 183) and makes extension by an India-rubber cord instead 
of a weight. 

Bonnet's wire cuirass of full size supporting the head, trunk, and both 
legs has been used occasionally and has advantages that may at times 



FRACTURES OF THE NECK OF THE FEMUR. 



519 



Fiff. 28: 



be useful. Extension can be readily applied by means of adhesive 
plaster, and counter-extension by a perineal band or by elevation of the 
foot of the bed as usual. It allows the patient to be moved and cleaned 
more readily than when he is lying in bed. It has been suggested that 
the various splints used in hip-joint disease are applicable also to the 
treatment of fracture ; their only advantage would be that they might 
make it easier to move the patient in bed or from the bed to a chair or 
sofa, or, later in the case, to get about on crutches. 

Hennequin advises that the limb should be kept abducted in order 
to relax the gluteal muscles and thus avoid their influence in causing 
shortening ; it seems probable that this advantage would be neutralized 
by the greater tension which the position would cause in the adductors. 
A modification which he sug- 
gests of Bonnet's cuirass is 
shown in fig. 282 and seems 
to possess some advantages. 
The thigh rests in the grooved 
splint, the foot and leg are 
wrapped in an immovable cot- 
ton dressing extending above 
the knee and rest on a chair 
beside the bed, the knee being 
partly flexed, and extension is 
made by a weight attached to 
a bandage about the upper 
portion of the leg. Counter- 
extension is provided partly 
by the weight of the body, 
partly by a depression in 
which the buttocks rest, and 
partly by a perineal band. I 
should prefer extension by 
weight in the usual manner to 
this arrangement which re- 
quires the leg to be kept out- 
side the bed, although patients 
with fracture of the shaft 
whom I have seen treated by 
Hennequin with a similar ap- 
paratus made no complaint of 
the position. The abduction 
can be easily got by placing 
the patient obliquely in the 
bed. 




Hennequin's splint for fracture of the neck of the femu 



In a few cases of painful pseudar 'thro sis operative attempts to relieve 
have been undertaken, either to secure union or to remove the head of 
the bone. The first of the kind was by Langenbeck 1 between 1850 
and 1860 ; he exposed the trochanter major and passed a silvered drill 



1 Deutsche Gesellsckaft far Chirurgie, vol. vii. 1878, p. 92. 



520 FRACTURES OF THE FEMUR. 

through it into the upper fragment so that it held them together. The 
patient was an old woman with an oblique fracture of the neck almost 
entirely extra-capsular which had remained ununited and very painful. 
The joint became inflamed, hospital gangrene attacked the wound, and 
the patient died. In Lister's case the patient survived, but the opera- 
tion secured only fibrous union. The case is briefly referred to by 
MacCormac, 1 but no details are given beyond the fact that the bones 
were not pegged together. 

Konig 2 was successful in 1875 by an operation similar to Langenbeck's. 
The patient was young and the operation was done antiseptically. A 
small incision was made down to the trochanter and a long metal drill 
passed through it into the neck, or at least in its direction. It is not 
stated whether or not the drill was left in place to hold the fragments 
together. 

It is said to be very difficult to keep the head of the bone steady 
during the boring and to pierce it at the proper point. Trendelenburg 3 
has proposed that the fracture should be exposed by an incision directly 
over it, the broken surface of the lower fragment exposed by extreme 
adduction of the limb, and the trochanter bored from within outward. 
Then the drill is removed, the limb straightened, the drill reinserted 
from the outer side and driven into the head, guided by a finger in the 
wound. A silver screw would then be used to fix the fragments together, 
the wound closed, suitable provision having been made for drainage, and 
the screw removed after a fortnight. 

Dr. Howe 4 removed the head of the femur nine months after fracture 
of the neck, union having failed. The patient was a woman, 62 years 
old, she recovered from the operation, but the limb remained completely 
useless. Apparently there was no active process going on at the seat of 
fracture at the time of the operation, the neck was almost entirely ab- 
sorbed, and the joint contained about a drachm of inspissated pus. 

B. Fracture through the Great Trochanter and Neck. — Since 
the publication of Sir Astley Cooper's work on Fractures it has become 
the custom to describe this variety of fracture separately, and a certain 
degree of vagueness or indefiniteness in the first description has been 
preserved in most of the subsequent ones. 

The class may be defined as composed of those fractures in which the 
line of fracture begins on the under surface of the neck at or near its 
junction with the shaft and passes obliquely upward and outward to the 
outer surface of the trochanter below its summit, dividing the bone into 
two parts, the upper one of which is formed by the head and neck and 
upper part of the trochanter. 

The recorded cases in which the character of the injury was shown by 
autopsy or made reasonably certain by the symptoms are few in num- 
ber. In the first, seen by Cooper while a student, bony union took 
place, death was caused by a fever shortly afterwards, and the fracture, 

1 Antiseptic Surgery, pp. 197 and 200. 

2 Deutsche Gresellschaft fur Chirurgie, vol. vii., 1878, p. 93. 

3 Idem, p. 91. 

4 N. Y. Medical Record, 1878, vol. xiv. p. 394. 



FRACTURES OF THE UPPER END OF THE FEMUR. 521 



so far as can be learned from the plate representing tne specimen and 
the brief description, passed through or just below the lesser trochanter 
and ran parallel to the spiral line. 

Another case described by R. W. Smith 1 as an extracapsular fracture 
(fig. 283). The details are scanty. The patient was 70 years old, and 
died on the fifth day. The limb was everted 
and shortened 1J inches. 

Of the four additional cases given by 
Cooper only one can be accepted ; in two 
the diagnosis remains obscure, and in the 
remaining one, which is quoted from Stan- 
ley (Med. Chir. Transactions, vol. xiii. p. 
504), the fracture seems to me to have been 
the common fracture at the base of the neck 
with some splintering of the trochanter and 
displacement of the upper portion of this 
part. The error in interpretation, which 
has been followed by others, is due to the 
deficient description which says " the frac- 
ture extends obliquely through the trochan- 
ter major and through the basis of the neck 
into the shaft of the femur ;" the accompany- 
ing plate shows a displacement of the upper 
and posterior portion of the trochanter with 
reference to the remaining portion that seems 
incompatible with the theory that it is un- 
brokenly continuous with the neck. A 
second and similar case, described in almost the same terms by Stanley 
in the same paper and with the same title, fracture of the trochanter 
major, is placed by Sir Astley in his chapter on fracture of the epiphy- 
sis of the trochanter. The point in each case which attracted Stanley's 
attention and which alone, in my opinion, distinguishes them from the 
ordinary fracture, is the free separation of a large upper fragment of the 
trochanter, in addition to the fracture of the neck, and its displacement. 
Similar cases have been reported by Michon 2 and Mercier 3 and quoted 
by Malgaigne as extra-capsular fractures. Mercier's case was thought 
to be a dislocation. 

The symptoms mentioned in Smith's case are simply eversion and 
shortening of 1 J inches, and in Sir Astley 's first case simply eversion. 
In the other in which the diagnosis appears reasonably certain there was 
slight shortening, the trochanter was drawn forward and could be felt 
considerably separated from that portion which remained connected with 
the neck of the bone ; the foot was turned outward, the patient could 
not sit, and the least attempt to rise caused great pain. 

The distinction from fracture of the neck would have to be made by 
recognition of the fact that the upper portion of the trochanter remained 




ill 

Fracture through the great 
chauter. (R. W. Smith.) 



1 Loc. cit., Case 43. 

2 Bull, de la Societe Auatomique, 1835, p. 

3 Gazette Medicale, 1835, p. 564, Obs. 3. 



37. 



522 FRACTURES OF THE FEMUR. 

connected with the neck, did not move with the lower fragment, and was 
not displaced backward as in Stanley's two cases. 

In two of these three cases the patients recovered with a useful limb ; 
one was able to walk freely in about a year, the leg remaining everted 
and shortened nearly an inch ; another died of an intercurrent fever as 
he was about to leave the hospital, there was very little deformity, only 
some eversion of the foot, and he walked well ; in the remaining case, 
Smith's, the patient died on the fifth day. 

The treatment should not differ from that of fracture of the neck : 
extension to overcome or prevent shortening, a side splint or Yolkmann's 
foot-rest to prevent eversion, and cushions to support the thigh. 

C. Fracture of the Great Trochanter. Separation of the Epi- 
physis. — Cases of this kind verified by post-mortem examination are rare, 
and those in which the diagnosis has been made upon the symptoms 
have been differently interpreted by the different authors. The cases 
verified by direct examination are the following. 

Aston Key 1 saw a girl 16 years old, who had fallen in the street and 
struck the trochanter against the curbstone. She rose and walked 
home without much pain or difficulty, but five days afterwards was ad- 
mitted to Guy's Hospital on account of pain felt on the inner side of the 
thigh. The limb was everted and appeared to be half an inch longer 
than the other. Passive motion was possible in all directions, but ab- 
duction Avas painful. She had perfect command over all the muscles 
except the internal rotators. No crepitus or displacement, and no swell- 
ing. She had a high fever and died nine days after the accident. 

The trochanter was found to be detached from the body and neck, but 

without rupture of the tendons attached to its outer side, and these acted 

as a hinge and allowed the fragment to move only 

Fig. 284. upward and downward. Fig. 284 represents this 

specimen which is preserved in Guy's Hospital 

Museum. 

Waechtei 2 saw a man 71 years old who fell while 
walking, struck upon his left hip, rose and walked 
home, and sought admission to the hospital a week 
later. There was no shortening, no sign of contu- 
sion; passive motion was painless, except outward 
rotation, and there was no crepitation. The hip 
became tender, and the limb took the position of 
Fracture or diastasis of flexion, adduction, and inward rotation ; the patient 

the great trochanter. r . , \ ,. , e . . L 

(Bryant.) grew feverish and died ot hypostatic pneumonia 

four weeks after the accident. 
The ligamentum teres was thickened and hypertonic, but there was 
no effusion in the joint. The upper and inner portion of the trochanter 
was separated by a line of fracture which lay entirely outside the joint, 
beginning close by the upper edge of the insertion of the capsule, run- 
ning downward and outward, and then up across the top of the trochanter. 

1 Cooper's Fractures and Dislocations, Case 100. 

2 Deutsche Zeitschrift fiir Chirurgie, vol. viii., 1877 ; p. 104. 




FRACTURES OF THE UPPER EXD OF THE FEMUR. 523 

The fragment, which was split into two pieces that were slightly movable 
on each other, was slightly displaced backward and inward, and the peri- 
osteum was torn in front, but not on the outer side. The tendons of the 
pyriformis, obturator internus, and gemelli, and the anterior fibres of the 
gluteus medius and upper fibres of the gluteus minimus remained 
attached to the fragment. There was no sign of repair, no extravasation 
of blood. A fissure three centimetres long in the shaft made the remain- 
ing half of the trochanter slightly movable. 

Another case was reported by J. Clarke in the Transactions of the 
Medical Society of Calcutta; 1 a man, thirty-two years old, fell while 
running and struck heavily on the left hip and thigh. He walked home, 
a short distance, with help. There was no deformity, no crepitus ; some 
swelling and contusion over the trochanter ; and any attempt to rotate 
the limb inward caused extreme pain. He died on the eighth day of 
delirium tremens. 

The trochanter was found to be crushed and shattered, several pieces 
entirely detached, and fissures extending deeply into the shaft. 

A case was reported by McCarthy 2 to the Pathological Society, and 
is printed in the Transactions as " a traumatic separation of the trochan- 
teric epiphysis," similar to Aston Key's quoted above. The patient was 
a girl, eight years old, who, when brought to the hospital, was consid- 
ered too ill to be examined, and died a few hours afterwards. The his- 
tory was that she had never had any illness previous to a fall upon the 
left side a week before while playing. A day or two later a lump was 
noticed on the left hip, and the child was kept in bed in consequence. A 
few days afterwards her breathing became so difficult that she was 
brought to the hospital, walking the distance, half a mile, and not com- 
plaining of pain. 

The autopsy showed " pysemic pericarditis, pleurisy, and pneumonia ; 
a large extra-peritoneal abscess in the pelvis connecting along the tendon 
of the pyriformis with another around the neck of the left femur. The 
trochanteric epiphysis was completely detached from the shaft, but held 
in position by tendinous attachments and the reflections of the capsule. 

The cases in which the diagnosis was not verified by direct examina- 
tion are one under the care of Poland, quoted and pictured by Bryant 
(loc. cit., p. 846), and one reported by Sir Astley Cooper, 3 as fracture 
through the trochanter, but which, as Malgaigne points out, was more 
probably of this kind. Bryant refers also to a case reported in the 
Canada Medical and Surgical Journal, Nov. 18T5, and Dr. Hamilton 
also reported a case as such, but now 4 doubts the correctness of his 
diagnosis. 

Cooper's patient recovered after a tedious illness, and had good use of 
the limb. In Hamilton's, displacement upward of the trochanter per- 
sisted, and the patient was able to walk with only a slight halt. 

The diagnosis would have to be made, during life, on the history of 
direct violence received upon the trochanter, the absence of symptoms 

1 Abstract in Am. Journal Med. Sciences, vol. xix., 1836, p. 181. 

2 Trans, of Pathological Society of London, vol. xxv., 1874, p. 200. 

3 Loc. cit., Case 96. 4 Loc. cit., p. 429. 



524 FRACTURES OF THE FEMUR. 

of fracture of the neck or of the shaft, localized pain, and possibly 
displacement of a portion of the trochanter. 

Cooper treated his case with a bandage drawn tightly about the hips, 
so as to press the fragment downward and inward. In view of the tend- 
ency of the attached muscles to draw the fragment upward and back- 
ward, it is probable that union would be favored by keeping the limb 
abducted and rotated outward. 

Agnew (loc. cit., p. 945) gives a figure of a specimen in his own pos- 
session, but adds no details of the case. He says only " there was pres- 
ent a considerable amount of granular callus around the circumference 
of the fracture, though there was none between the fragments." 

2. Fractures of the Shaft of the Femur. 

In this division will be included fractures just below the lesser tro- 
chanter, which are sometimes described separately under the title of sub- 
trochanteric ; fractures just above the condyles will be described in the 
section on fractures at the lower end of the femur. 

The causes of fracture are direct and indirect violence and muscular 
action. Examples of the latter have been quoted in Chapter IV. ; an 
additional one, which may deserve mention as probably the earliest on 
record, although hardly typical, is quoted by Pouteau j 1 a lad seventeen 
years old, while standing on the deck of a vessel which was rolling 
heavily, put out his right foot suddenly to save himself from falling ; he 
uttered a loud cry, and his right thigh was found to have been fractured 
with displacement. 

A case of fracture by convulsive muscular contraction, in a patient 
whose femur had been weakened by disease and the formation of a 
medullary abscess, is reported in the Lancet for Aug. 23, 1879, p. 279. 
The patient was forty years old, and had long suffered from the effects 
of a kick upon the thigh by a horse, effects consisting in the formation 
of abscesses, the discharge of small pieces of bone, and spasm of the 
muscles. During a violent spasm the bone was heard to snap. The 
spasms continued to be frequent and painful, and the limb at last was 
amputated. The fracture was at the junction of the lower and middle 
thirds, and was deeply serrated ; the medullary canal was much dilated 
for about two inches and the cortex thinned, but there was no seques- 
trum. Dr. Agnew 2 refers briefly to two cases, one, under his own care, 
caused by the effort to avoid a fall after tripping, the other by turning 
in bed, and expresses the opinion that degeneration of the bone is a 
necessary preliminary to such a fracture. 

Fractures by direct violence are caused by the passage of the wheel 
of a wagon, the kick of a horse, a fall across a rail, a blow by the pole 
of a wagon : fractures by indirect violence by a fall upon the knees or 
feet, and, very rarely, by torsion, as when the foot is held and the body 
turned. 

All the varieties of fracture that may occur in long bones are met with 
in the femur, but in the great majority of cases the fracture is oblique 

1 (Euvres Posthumes, 1783, vol. ii. p. 254. 2 Loc. cit., p. 946. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



525 



and often extremely so, the obliquity usually corresponding to the normal 
curves of the bone ; that is, in the middle part of the bone it runs from 
behind forward and downward, and in the upper third forward and 
outward. Transverse fracture is rare in adults, but common in children 
where the periosteum also remains in part untorn. 



Fig. 285. 



Fig. 286. 



Fig. 287. 





Toothed fracture of the femur. 



Oblique fracture of the femur. 



Transverse fracture of the 
femur. (Gurlt.) 



The displacement is marked, and is the effect of the fracturing cause 
and of the contraction of the powerful muscles of the thigh ; the. lower 
fragment usually passes behind and to the inner side of the upper one 
and is sometimes rotated outwardly ; in addition there is angular dis- 
placement, the angle usually being directed forward or forward and 
outward, but sometimes backward or inward. 

Inclination forward and outward of the lower end of the upper frag- 
ment after fracture in the upper third is the rule, and is mainly due to 
muscular action, to the contraction of the gluteal muscles and the psoas 
upon the upper fragment and of the adductors and the flexor of the leg 
upon the lower one.' The tendency of the former is to tilt the upper 
fragment forward, outward, or in both directions ; that of the latter is to 
draw the lower fragment up against the upper one, and this will produce 



526 



FRACTURES OF THE FEMUR. 



an angular displacement in any direction that is favored by the line of 
fracture. The fact that the displacement is sometimes backward or in- 
ward does not disprove the influence of the muscles attached to the upper 
fragment, as has been argued ; the principal agency is the drawing upward 
of the lower fragment, and if the fragments are so related at the seat of 
fracture that the upper one is pushed in a different direction from that 
in which its muscles would draw it the latter must yield. In the extreme 
case figured by Sir Astley Cooper (fig. 288) it can be seen how great 
the angular displacement and at the same time the overriding can be 
under these circumstances. The angular displacement necessarily pro- 



Fig. 288. 



Fig. 289. 





Fracture of the upper third of the femur ; 
union with great displacement. (A. Cooper.) 



Transverse fracture of the femur. (Gurlt.) 



duces shortening, and this shortening varies according to the angle and, 
the angle being the same, according to the distance of the fracture below 
the ne.ck of the bone. In the same specimen outward rotation of the 
lower fragment is also very marked. In transverse and toothed fractures 
the displacement may be lateral or angular or both, and if the lateral 
displacement is sufficient to free the fragments they may override, as in 
figure 289. 

Fissures extending upward and downward from the seat of fracture 
are probably not infrequent, especially in gunshot fractures. A notable 
example has been quoted from Prof. Bigelow, page 496. 

Double fractures have been observed, and, according to Malgaigne, 
there is a specimen of triple fracture in the Musee Dupuytren. Com- 
minuted or splintered fractures are not uncommon, especially among frac- 
tures by direct violence, and the splinters may be large (fig. 290.) 



FRACTURES OF THE SHAFT OF THE FEMUR 



527 



The symptoms are pain, loss of function, abnormal mobility, deformity, 
and crepitation. As the bone is deeply placed under thick muscles 
irregularity in its outline cannot be recognized 
by the touch ; angular displacement can often Fig. 290. 

be readily recognized in thin patients by the 
eye, but the method of examination which renders 
the best service in this respect is the compara- 
tive measurement of the two limbs. The fixed 
points commonly used for this purpose are the 
anterior superior spinous process of the ilium 
and tip of the external malleolus ; the rules for 
making these measurements and the precautions 
to be taken to guard against error have been 
given in Chapter V. and in the preceding sec- 
tion of this chapter, page 510 ; the capital point 
is to make sure that the two limbs form the same 
angle with the pelvis, and the best method of 
doing this is to stretch a tape across the abdo- 
men from one anterior superior iliac spine to 
the other, and a second one at right angles to 
the first from its centre downward, and then to 
place the ankles at equal distances from the 
second line. 

If the upper limit of the great trochanter can 
be distinctly made out the measurement may be 
made from it to the external malleolus ; or instead 
of making the measurements the surgeon may 
simply note the difference in the positions of the 
internal malleoli as they lie side by side. Of 
course it is essential in the latter case that the 
limbs make the same angles with the pelvis. 
The shortening may vary from a small fraction 
of an inch to two, four, or even six inches. 

Abnormal mobility may be recognized by 
placing the hand under the thigh at the suspected 
seat of fracture and gently lifting it, or by hold- 
ing the upper portion of the thigh down with one 
hand and gently lifting the leg or moving it from 
side to side with the other, or by observing 
whether the great trochanter moves with the leg when the latter is gently 
rotated. 

Usually the diagnosis can be made upon the pain, the powerlessness 
of the limb, the shortening, and the facility with which the shortening 
can be overcome by traction. The examination for abnormal mobility 
and crepitation should be made very gently, and should not be prolonged 
if the latter is not promptly obtained. 

Extreme obliquity of the fracture, which is not uncommon, leads occa- 
sionally to a complication which may be very troublesome and may trans- 
form a simple fracture into a compound one, the penetration of the 
muscle and sometimes of the skin by the sharp end of the upper frag- 




Fracture of the neck of the 
femur and of the shaft. A 
splinter, a, 5 inches long and 
nearly 1 inch wide, composed 
of the cortical layer, has been 
turned completely about its 
loug axis and become united, 
with its original periosteal sur- 
face in contact with the other 
fragments. (Figured by Guilt 
from the Museum of the Royal 
College of Surgeous, England, 
No. 454.) 



528 FRACTURES OF THE FEMUR. 

ment. Other complications are rare, the vessels and nerves not being 
in sufficiently close relations to be often injured. Laurent 1 found only 
two cases in which the artery had been injured ; one was a fracture in 
the lower third caused by the kick of a horse, the other a secondary 
fracture after union with displacement. 

A simple fracture without displacement, or suitably reduced, will 
usually consolidate in six or seven weeks sufficiently to allow the patient 
to get about on crutches, and he will be able to bear his weight safely 
upon the limb, and to discard the crutches in three or four weeks more. 
In exceptional cases the consolidation may be delayed, and it happens 
occasionally that a secondary fracture occurs soon after the patient first 
leaves his bed, usually in consequence of a fall. Gosselin, who has seen 
this accident happen on the 70th and 75th days, prefers to keep his 
patients in bed until the 80th or 90th day. 

The effusion into the knee-joint which is observed so frequently in the 
course of fractures of the thigh has received particular attention since 
1870, when Rouge, of Lausanne, first wrote concerning it. Among 
those who have studied it most carefully are Gosselin, 2 Berger, 3 
Marjolin, Alison, 4 and Hennequin, 5 the two former attributing it to 
the passage of extravasated blood into the joint, the third and fourth 
to interference with the return venous circulation, and the last, in 
common with Verneuil and others, to an associated sprain. Others again 
have sought the cause of the effusions noted in the later periods of the 
case in the prolonged immobility and the extended position. An appre- 
ciable effusion makes its appearance in a majority of the cases within 
the first three days following the injury ; it is most prompt in children, 
and when the fracture is in the lower third, and is more common after 
fracture by indirect than after fracture by direct violence. It disappears 
promptly in children, more slowly in adults, and may persist for years. 

Prognosis. — Any fracture of the femur is a serious injury, to this 
extent, that its proper treatment makes confinement to the bed for sev- 
eral weeks desirable, that it will make it difficult for a long time for the 
patient to get about even with crutches, and that it may lead to shorten- 
ing of the limb, even if not to a persistent limp. 

Most authorities assert that an oblique fracture of the shaft of the 
femur cannot be cured without some permanent shortening. Since the 
time of Desault the possibility of a better result has been claimed by 
different surgeons, and for different dressings, but no method has yet 
won a general acceptance of its claim. While there is no reason to 
doubt the possibility of a union without shortening, and while I believe 
such union has been obtained in some cases, I do not believe there is any 
method of treatment which can be depended upon to secure it in any 
given case, for it can never be known in advance whether or not the 
patient will be able to support the traction and pressure necessary to 
success. Some surgeons have claimed an actual elongation of the limb 

1 Des AneVrysmes compliquant les Fractures. These de Paris, 1874. 

2 Clinique de l'Hopital de la Charite. 3 These de Paris, 1873. 

4 These de Paris. 

5 Loc. cit., p. 78. (See also the discussions in the Bulletins de la Societe de Chirur- 
gie, 1878, pp. 6 and 336.) 



FRACTURES OF THE SHAFT OF THE FEMUR. 529 

by the use of continuous extension. Although a certain doubt is thrown 
over such assertions by the acknowledged difficulty of making accurate 
measurements, and by the possibility of a previously existing inequality 
in the length of the limbs, the occurrence is not impossible, however 
improbable it may be thought. 

The persistence of some shortening, even an inch, does not necessarily 
cause the patient to limp, since it is readily compensated for by an 
inclination of the pelvis. The rigidity in the knee is likely to persist 
for a length of time that is greater as the patient is older and of a rheu- 
matic habit. 

The prognosis in compound fractures is particularly grave when the 
injury has been produced by direct violence ; and in a fracture of both 
thighs, particularly if either is compound, the shock is usually so great 
as to put the patient's life in serious danger. 

Treatment. — The different methods and apparatus that have been em- 
ployed in the treatment of fractures of the thigh are very numerous, 
and most of them have been abandoned in favor of a few whose merits 
and superiority have won general recognition. 

Buck's Extension Apparatus. — Prominent among them is the method 
of continuous extension with which the name of the late Dr. Gurdon 
Buck is associated. It is simple in construction, easy of application, 
causes no pain to the patient, and allows thorough examination of the 
limb at all times. It is the method which I use habitually, and I believe 
it to be the one in most general use in New York. 

The details of its application have been described in the chapter on 
Treatment, page 181. Figure 291 shows how the - strips of adhesive 

Fiff. 291. 




Adhesive plaster applied for extension. 

plaster are made fast, and figure 292 shows the limb resting upon a 
Volkmann's sliding rest, with the weight and the short coaptation splints. 
A perineal band for counter-extension is unnecessary if the foot of the 
bed is raised about six inches. When Volkmann's rest is used a thin 
cushion or folded sheet should be placed under the thigh to support it, 
and it is usually desirable to make special pressure with cushions or sand 
bags below and on the outer side of the thigh to correct any angular dis- 
placement or oppose the tendency of the upper fragment to rotate out- 
wardly. This latter tendency should be especially watched for and 
opposed ; the patients often show a strong inclination to lie partly on the 
injured side, instead of squarely on the back, and when they do so the 
pelvis sinks on that side and rotates the upper fragment outward, while 
34 



530 



FRACTURES OF THE FEMUR. 



the lower fragment and foot are kept stationary by the dressings. Even 
when the patient lies flat on his back the trochanter can sometimes be 
seen to occupy a more posterior position than the one on the other side, 



Fis. 292. 




Volkmann's sliding rest foi* fractures of the thig 



to be rotated outward, and it must either be held up on cushions or the 
foot and lower segment must be rotated in the same direction by raising 
the inner side of the sliding rest. 

Besides its simplicity of construction the method has the other merit 
of allowing a certain liberty of motion and choice of position to the pa- 
tient which make his confinement less irksome, less dangerous, and less 
likely to cause bedsores. It is unnecessary to keep his head and 
shoulders low, he can sit up in the bed, resting on pillows, and can. move 
himself up and down with a freedom quite as great as that furnished by 
a suspended splint. Indeed, it is rather startling to see the apparent 
recklessness with which a patient will raise himself upon his elbows and 
draw himself rapidly up in the bed. The sliding-rest and the weight and 
pulley furnish a valuable combination of solidity and freedom. 

Care should be taken to carry the adhesive straps and the roller 
bandage which secures them several inches above the knee, if the posi- 
tion of the fracture permits, in order to take some of the strain of the 
weight off the ligaments of that joint ; and when the fracture has been 
above the middle of the shaft I have sometimes reapplied the strips after 
the third week so that they would adhere only to the lower part of the 
thigh, and would leave the leg free for passive motion at the knee. 

The roller bandage which secures the strips of adhesive plaster is 
sometimes coated with silicate of soda to give it a smooth finish and 
make it more solid, but the practice seems to me to be undesirable be- 



FRACTURES OF THE SHAFT OF THE FEMUR 



531 



cause of the unpleasant reaction of the impervious coating upon the skin. 
The same objection applies to plaster of Paris. 

The pulley should be in the line of the axis of the limb or slightly 
above it, and the end should be long enough to allow the limb to be 
moved up and down in the bed for the distance of a foot or eighteen 
inches. If a pulley cannot be obtained one can be extemporized out of 
a spool and a stout iron rod or wire. The weight must vary according 
to circumstances ; fifteen or twenty pounds are usually required at first 
for a healthy stout adult, and it may be reduced one-half after the third 
week. 

The coaptation splints, three or four in number, should be ten or 
twelve inches long and two inches wide, suitably padded, and made fast 
with straps or pieces of bandage that can be tightened at will. A plaster 
of Paris casing, made with the ordinary plaster roller, and extending 
from the knee to the trochanter, is an excellent substitute for the wooden 
splints after the first or second week. 

As soon as the abnormal mobility is lost the limb may be enveloped 
in plaster, and the patient allowed to go about on crutches. I think it 
is imprudent to make this change before all danger of the occurrence of 
shortening has passed, and as a test of this I remove the weight for a 
day or two ; if the limb does not shorten during this time I apply the 
plaster, if it does shorten I reapply the weight. The plaster dress- 
ing should include the leg and the pelvis, and need not be very heavy, 
since it is intended only to give additional support and to guard against 
accident. It should be kept on for two or three weeks and reapplied if 
on examination the union appears insufficient or tender. The danger to 
be guarded against in the later stages of treatment is that of secondary 
fracture, rupture of the callus, by a comparatively slight cause. It 
arises when the patient leaves his bed and continues for some time 
thereafter, even to the end of the third month, and it should be im- 
pressed strongly upon the patient, especially upon the young and active 
who chafe under the confinement and are anxious to prove to themselves 
that they are well. With such patients confinement to the bed and 
encasement in plaster should be prolonged beyond the usual time. 

Fig. 293. 




Long side splint. (Hamilton.) 



Dr. Hamilton uses in addition to the weight a long side splint with a 
cross-bar at the foot (fig. 293) to give additional steadiness to the frag- 
ments and to prevent rotation. The sliding-rest, which is of later intro- 



532 



FRACTURES OF THE FEMUR. 



duction, meets the latter indication equally well and has advantages of 
its own. If it is thought desirable to give the fragments more support 
than the short coaptation splints supply, a moulded thigh-piece of plaster 
or pasteboard may be added. 

Long side splint. — In the long side splint, single (fig. 294) or double 
(fig. 295), an India-rubber cord is substituted for the weight and pulley, 

Fig. 294. 
DouUc fiull&fj 




In(LRul)ler 'Accumulator 
Long single side splint and India-rubber extension. 

and the dressing is entirely independent of the bed. Counter-extension 
is made in the single splint by a perineal band, and in the double one by 
a brace for the foot on the uninjured side. The India-rubber which 



Fig. 295. 




India ru&tser 
Accuntultztcr 

Double side splint. (Cripp's.) 

makes the extension is attached to the limb as in Buck's method by 
strips of adhesive plaster secured by a roller bandage. 

The single splint must be long enough to reach from a few inches be- 
low the foot to the axilla, and is sometimes bracketed opposite the tro- 
chanter. After the adhesive strips have been applied the splint is placed 
against the outer side of the limb and body with a long, narrow, well- 
padded cushion between, and made fast at the upper end to the perineal 
band which must be well padded and fitted smoothly to the groin. Then 
extension is made upon the foot by an assistant to bring the limb down 
to its full length, and the cord is carried around the pulley at the bottom 
of the splint and made fast to the rubber. Finally, a body bandage is 
passed about the upper end of the splint and the chest. 

In the double splint the perineal band is gotten rid of by making the 
counter-extension through the opposite limb, and by raising the foot of 
the bed two or three inches. The apparatus is sufficiently well shown 
in figure 295 to render a detailed description unnecessary. Mr. Bryant 
speaks highly of this splint, saying that in 31 cases treated with it con- 
secutively by him there was no shortening in 18, less than half an inch 
in 10, and in only 3 did it amount to an inch. 

The disadvantages of this method, as compared with Buck's extension, 



FRACTURES OF THE SHAFT OF THE FEMUR 



533 



are in the use of the perineal band and in the more rigid confinement to 
one position in the bed. On the other hand it probably keeps the frag- 
ments steady. 

Various attempts to do away with the perineal band by the substitu- 
tion of other methods of making counter-extension have been made but 
have not gained much favor. Sir Win. Ferguson applied " counter-ex- 
tension from a strong stay of jean carefully fitted to the opposite thigh, 
from which a band extended in front and behind to the upper end of the 
splint." Mr. Campbell de Morgan places the long splint on the unin- 
jured side for counter-extension, and makes the extension about a pulley 
placed on a crosspiece at the foot (fig. 296). Dr. Hodge prolonged the 

Fig. 296. 




Roll e with Cent- fastener for India, rubber 

Extension of affected limb Accumulator 

Campbell de Morgan's splint. 



splint beyond the shoulder by means of a bent iron rod and mide the 
counter-extension by strips of adhesive plaster fastened to the front and 
back of the chest. 

Hennequiri' 's splint, which seems to have become quite a favorite in 
France, consists of a gutter of wire gauze in which the thigh lies (fig. 
297) with the knee bent and the foot resting on a support by the side 

Fig. 297. 




Hennequiu's apparatus for fracture of the femur. 



of the bed. Counter-extension is made by three pads attached to the 
upper end of the gutter. The lower one is in the form of a crescent, 
and takes its bearing against the ischium, the other two are attached to 
adjustable rods, Gr and H in the figure, and rest against the pubes and 
ilium. Extension is made by elastic bands fastened at one end to a 
padded leather band which buckles about the lower portion of the thigh 
and buttoned at the other to the ends of the side pieces of the gutter. A 



534 



FRACTURES OF THE FEMUR 



second pair of elastic bands attached to the same bars make traction 
against the back of the upper part of the leg. The foot and leg are 
wrapped in cotton batting and the lower end of the gutter is swung from 
any convenient fixed point above the bed. 

Anterior splint. — The suspended anterior splint introduced by Nathan 
R. Smith (fig. 298), and modified by Prof. Hodgen is highly esteemed 

Fi<?. 298. 




Nathan E. Smith's anterior splint. 



by some surgeons, especially in the treatment of compound fractures. 
Extension is made by having the point of suspension beyond the foot, 
and counter-extension by the weight of the pelvis. Smith's splint is 



Fi<?. 299. 




made of parallel rods of iron wire bent to fit at the knee, ankle, and 
groin ; it is placed along the front of the limb and made fast to it with a 
roller bandage or with strips of stout muslin or leather passing under 
the limb from one side to the other. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



535 



Hodgen's splint is rather stouter, and the bars pass beside the limb 
and beyond the sole of the foot instead of in front. It is secured to the 
limb by strips of adhesive plaster and a stirrup as in Buck's extension, 
the limb rests upon broad strips of bandage or straps passing under it 
from one side to the other, and the whole is suspended as shown in figure 
299, which is said by Mr. Bryant to represent the manner in which it is 
used at Guy's Hospital. 

The Plaster of Paris Dressing. — This form of the immovable dressing 
had a notable return to favor in this country between 1870 and 1875. 
It was introduced into Bellevue Hospital by Dr. Sands and Dr. McBur- 
ney, at that time his house-surgeon, and the extensive use that was sub- 
sequently made of it was largely due to the excellence of the results 
obtained with its aid in that hospital. The claims made for it were 
somewhat exaggerated and it is now used very much less than it was a 
few years ago. I have not seen a recent fracture of the thigh thus treated 
in Bellevue or the Presbyterian hospital in several years, and on inquiry 
of the surgeons of the New York, Roosevelt, and St. Luke's hospitals 
I learn that its use is equally restricted or aban- 
doned in those institutions. Mr. Erichsen, 1 how- 
ever, says he has treated many fractured thighs 
with this or the similar starch dressing " without 
confinement to the bed for more than three or four 
days, and without the slightest apparent shortening 
or deformity being left." A fracture of the thigh 
is, in my opinion, a sufficiently serious injury to 
make it worth the patient's while to remain in bed 
for a month, and the advantages to be obtained by 
getting him out of bed in the first week can seldom 
compensate for the risk it involves of producing an 
inferior result, perhaps a life-long deformity. 

The general details of the application of the 
bandage have been given on page 174 ; among the 
special ones are the following: The bandage may 
be first applied to the foot, ankle, and lower part 
of the leg and allowed to harden, then the patient's 
body is raised above the bed or table by a sling 
passed about his waist and attached to a support, 
counter-extension is provided for by a well greased 
perineal band or an upright rod made fast to the 
table and padded so that it will not chafe the perineum against which it 
rests, and then traction is made upon the foot. When the limb has 
been drawn down to its full length the remainder of the plaster dressing 
is applied, and is strengthened at the groin by a piece of blanket or simi- 
lar loose meshed material soaked in plaster cream and laid over the 
anterior and outer aspects of the region. Extension must be kept up 
until the plaster has hardened. Anaesthesia may be used to diminish the 
resistance of the muscles or pressure made upon the femoral artery. If 




Plaster of Paris dress- 
ing ; fracture of thigh. 
(Erichsen.) 



1 Science and Art of Surgery, Am. ed., 1873, vol. i. p. 376. 



536 



FRACTURES OF THE FEMUR 



the patient is allowed to get up the limb should be supported by a sling 
passing under the sole and about the neck. 



Fig. 301. 




^sa^s^sss 



Fracture of the femur. Waiting for the plaster to set. 

Fracture of the Thigh in Children.— Extension by weight and pulley 
is not satisfactory in these cases because of the restlessness of the patient, 
and the soiling of an immovable apparatus by the feces and urine will 
often make a change necessary. The practical difficulties in the way of 
the usual dressings have seemed so great that some of the most experi- 
enced surgeons, Paget and Callender, 1 have discarded them entirely and 
have treated many such fractures without splints, " the child being laid 
on a firm bed, with little or no head pillow, with the broken limb, after 
setting it, bent at the hip and knee and laid on its outer side." This 
practice may answer in some cases of transverse frac- 
Fig. 302. ture without rupture of the periosteum, but I should 

not be willing to trust to it. 

Mr. Bryant 2 recommends " that the injured limb of 
the child, together with the sound one, be flexed at a 
right angle with the pelvis, fixed with some light 
splint, and hoisted upwards to a cradle, hook, or bar 
above the bed. (Fig. 302.) By these means the 
weight of the body acts as a constant counter-extend- 
ing force, the child can be well looked after for pur- 
poses of cleanliness, and a good result may be ex- 
pected. At Guy's we have had excellent results from 
this practice." Lentzt 3 reported a case treated in this 
manner on Schede's suggestion very satisfactorily. 
The child was f J years old and the thigh was broken 
between the middle and upper thirds ; extension was 
made by strips of adhesive plaster attached in the usual 
manner, the cord was carried over a pulley immediately 
above the pelvis, and the weight, 4J pounds, was 




Fracture of the femur 
iu a child, treated by 
vertical extension. 



1 St. Bartholomew's Hospital Reports, 1867, p. 385. 

2 Practice of Surgery, 3d Am. ed., p. 849. 

3 Berliner Klin. Wochenschrift, 1880, No. 52. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



537 



enough to make the pelvis, with a little aid from the hand, swing clear. 
The child appeared to be perfectly comfortable during the four weeks the 
position was maintained, and frequently sat upright in the bed, his body 
parallel to the limb. Lentze suggests that a cross-bar should be attached 
to the foot to slide between two pairs of vertical rods and prevent ro- 
tation. 

Moiling 1 makes the apparatus independent of the bed, so that the 
child can be taken into the air. He lays the child on its back on a well- 
padded board to which a barrel hoop is fixed so as to be directly over the 
pelvis, and to this the foot is attached by an elastic cord. The child is 
also tied fast to the board. 

It has been asserted that the confinement to this position is dangerous 
because likely to cause trouble in the lungs. Kiimmell 2 has answered 
the objection by reporting the results of the treatment in forty cases, 12 
under one year, 16 between one and two years old, and 12 more than 
two years old: 3 died, of causes independent of the fracture ; in all the 
others the result was satisfactory. In one case the extension was kept 
up for 111 days, and in another for 104 days without causing the least 
trouble. An increase in the length of the limb, amounting to from one to 
two centimetres, which occurred not infrequently, disappeared under use. 

Dr. Hamilton uses a double long side splint with a cross-bar at the 
lower end (fig. 303). The splints reach nearly to the axilla on each 

Fisr. 303. 




i 




Hamilton's splint for fractnre of the femnr in children. 

side, and the limbs and body are made fast to them with a roller bandage. 
Coaptation splints, a perineal band, or elastic extension may be added if 
desired. 

The wire cuirass used in disease, or after excision, of the hip-joint 
furnishes a convenient means for immobilizing the limb and making ex- 
tension. 

Gritti 3 published the results of the treatment of 38 cases of fracture of 
the thigh in children under the age of seven years by weight and pulley. 
The points of special interest are that in the great majority of cases the 



1 Central blatt fur Chirurgie, 1882, p. 292. 

2 Berliner Klin. Wochenschrift. 18^2, No. 4. 

3 Centralblatt fur Chirurgie, 1881, p. 155. 



538 FRACTURES OF THE FEMUR. 

fracture had consolidated by the twentieth day, the minimum was eleven 
days in a child one year old, the maximum sixty days in a rachitic child. 
For the treatment of compound fractures and failure of union the 
reader is referred to the chapters on those subjects. 

3. Fractures at the Lower End of the Femur. 

In this group are included fractures at or just above the base of the 
condyles, the supracondyloid fractures, intercondyloid fractures, separa- 
tion of the lower epiphysis, and fracture of either condyle. 

These fractures may be produced by indirect violence, as in a fall 
upon the feet or the knees, or by the fall of the body when the leg has 
become fixed by slipping into a hole or between the rounds of a ladder, 
or by direct violence as in the passage of the wheel of a wagon or in a 
blow received directly upon the part. The special importance of the 
fracture is found in the proximity or direct implication of the knee-joint 
and in the difficulty of exercising an efficient control over the compara- 
tively small lower fragment. 

A. Supracondyloid Fracture and Separation of the Epiphysis. 
— In this class are included fractures of the shaft lying within the lower 
four inches of the .bone, fractures which are relatively more common in 
early life when compared with fractures of or between the condyles. 
The fracture is commonly produced by indirect violence, a fall upon the 
feet or knees, and in some cases by avulsion as above mentioned, the leg 
being fixed while the body is projected forward or to one side. 

The fracture is usually oblique, and from above forward and down- 
ward, but the obliquity may be in any direction and may be so slight 
that the fracture is almost transverse. Quite a number of cases of trau- 
matic separation of the epiphysis have been reported ; one of them, seen 
by Chauvel 1 in 1872, is unique. It was produced in an attempt to 
straighten a knee that had become ankylosed in a faulty position in con- 
sequence of a tumor albus. An abscess formed and the patient died of 
pyemia. 

Asa result of the usual obliquity in the direction of the line of frac- 
ture the fragments override, the upper one passing in front of the lower 
and its point sometimes engaging in the substance of the quadriceps 
muscle or its tendon or even perforating both it and the skin. Boyer 
maintained that the lower fragment turned upon its transverse axis so that 
its articular surface looked more or less directly forward, and its frac- 
tured surface backward, but this displacement has been shown to be rare. 
It exists in some cases ; Treiat 2 reported one in 1854, Broca, 3 Follin, 
and llichet, each one in 1857, but usually the fragments remain nearly 
parallel to each other. When the fracture is oblique, backward and 
downward, and in some cases of transverse fracture or separation of the 
epiphysis, the lower fragment is displaced forward. In either case the 

1 Diet. Encyclopedique, Art. Cuisse, p. 233. 

2 Archives Grenerales de Med., 1854, vol. ii. p. 78. 

3 Bull, de la Societe de Chirurgie, vol. vii., 1857, p. 297. 




FRACTURES AT THE LOWER END OF THE FEMUR. 539 

popliteal vessels may be so pressed upon as to cause gangrene of the 
parts below. The tilting backward of the upper end of the lower frag- 
ment, when it occurs, is due to the contraction of the gastrocnemii, and 
the displacement is opposed by the adductor magnus. Malgaigne denied 
that this angular displacement ever occurred, but although Boyer over- 
stated its frequency, and although the clinical proof claimed by so many, 
the presence of a hard mass in the popliteal space which is made less 
prominent by flexing the knee, is insufficient, yet its occasional occur- 
rence has been demonstrated post mortem. 

Separation of the epiphysis, which is theoretically possible until about 
the 25th year of life, has been observed at different ages between the 
moment of birth and the 16th year. Manquat 1 
collected 106 cases, of which 20 were of the lower Fig. 304. 

end of the femur. It has been produced by direct jg MM 

violence, but more commonly by traction upon the / , , ^B 

leg with torsion, or by hyper-extension of the knee 
as in Coural's 2 case, the first one reported with de- 
tails, a boy 11 years old who engaged his leg in a 
hole and fell forward. Volkmann 3 calls attention 
to the facility with which this accident takes place 
when the hip-joint is diseased ; he says he has pro- 
duced the separation, at the lower end of the femur, separation of the lower 
three times in such cases by the traction made in epiphysis of 

t . t -i • i • i (Bryant.) 

applying a plaster dressing or the rotation in seek- 
ing for crepitus. In several cases it has been produced by the leg be- 
coming engaged between the spokes of a wagon wheel in motion. In a 
few cases it has been caused intentionally to remedy a genu valgum, and 
once accidentally by Chauvel, as above mentioned, in an attempt to 
straighten a knee that had become fixed at a right angle in the course of 
a white swelling of that joint ; the straightening was easily effected, but 
abscesses formed and the patient died of pyaemia. The autopsy verified 
the diagnosis. Some of the cases have been compound from the begin- 
ning, others have become so by suppuration at the seat of fracture and 
opening of the abscess. The diagnosis in the compound cases may be 
made by recognition of the cartilaginous layer on the surface of one of 
the fragments, usually the lower one ; in the simple ones by the position 
and direction of the fracture and the age of the patient. It is possible 
that the growth of the limb may be checked in consequence. 

The diagnosis of supracondyloid fracture is not difficult. In addition to 
the usual signs of loss of power, pain, crepitation, and abnormal mobility 
we usually find a deformity which is characteristic, a dropping back- 
ward of the lower fragment and upper part of the leg, and a projection of 
the patella forward, especially of its upper end. In consequence of the 
overriding the patella is freely movable unless the tendon of the quadri- 
ceps is penetrated by the sharp end of the upper fragment and the 
patella fixed between it and the head of the tibia. 

1 Surles decollements epiphysaires traumatiques. These de Paris, 1877. 

2 Archives Generales de Med., vol. ix., 1825, p. 337. 

3 Virchow's (Canstatt's) Jahresbericht, 1866, ii. p. 337. 



540 



FRACTURES OF THE FEMUR 



B. Intercondyloid Fractures (fig. 305). — In these fractures both 
condyles are separated from the shaft and from each other, the line 
being T- or Y-shaped. The fracture is sometimes classed as a supra- 
condyloid fracture with splitting of the lower fragment, since that is 
thought to be the mode of production in most cases ; the shaft is first 
broken and then the upper fragment penetrates and splits the lower (fig. 
306). The claim that the fracture is caused by a violence transmitted 



Fte. 305. 



Fig. 306. 





Iutercondyloid fracture of the femur. 
(Bryant.) 



Comminuted fracture of the femui 
splitting of the condyles. 



with 



through the patella which acts as a wedge and splits off the condyles 
does not bear the test of experiment or harmonize with the fact that in a 
fall the blow is rarely received upon the patella. Trelat, 1 in the elabo- 
rate article in which it was first sought to give a detailed and full 
account of the fracture of. the lower end of the femur, points out that 
in six cases of supracondyloid fracture the average age was 2TJ- years, 
while in thirteen cases of intercondyloid fracture it was 48J years. The 
number of the cases seems to me too small to warrant the inference that 
this difference is an essential and constant one. 

The line of fracture, the general direction of which is commonly ob- 
lique, may be very irregular and may separate many and large splinters. 
The line between the condyles follows the intercondyloid notch, and is 
vertical and antero-posterior. In a case observed by Nelaton and re- 
ported by Trelat (loc. cit., p. 73), the mechanism of the separation of the 
condyles is shown plainly, the upper fragment being impacted into the 
lower one, but mainly on the inner side, and the separation of the con- 
dyles merely a fissure (fig. 307). Usually, however, the condyles are 
completely detached from each other and sometimes separated far enough 



1 Archives Generales deMed., 1854, ii. p. 59. 




FRACTURES AT THE LOWER END OF THE FEMUR. 541 

to allow the patella to sink in between them, and either Fig- 307. 

may be displaced backward farther than the other, 
with a corresponding rotation of the leg since the 
tibia retains its connection with them. The crucial 
ligaments may be torn longitudinally or transversely, 
and then the attachment of the tibia is less close. 
The pointed upper fragment perforates the quadri- 
ceps muscle and the skin in a large proportion of 
cases ; in 23 cases of supra- and intercondyloid 
fracture collected by Trelat the skin was perforated 
in 6 and the muscle alone in 6. There is also the 
same possibility of injury to the popliteal vessels or 
of pressure upon them by the end of the upper frag- 

, Intercondyloid fracture 

ment. of femur 

Intercondyloid fracture of both femurs is a rare and 
very grave injury. In a case under my care at Bellevue, the patient never 
rallied fairly from the shock and died in thirty-six hours ; one fracture 
was compound by perforation of the muscle and skin in front by the upper 
fragment, the other was simple, but the popliteal vein was torn, and 
there was a large extravasation of the blood in the thigh. In each the 
lower end of the upper fragment was very irregular but not broken 
obliquely, and there was much comminution between it and the condyles; 
the compact layer on the posterior face of the bone was pressed in 
toward the centre as if the lower fragment had been bent violently back- 
ward upon the other. The injury was caused by a fall from a height of 
about forty feet. 

Shortening of the limb is common, but the sign is one that is seldom 
needed for the diagnosis ; in an impacted fracture it might be useful in 
distinguishing the lesion from fracture of one condyle alone. 

Enlargement of the knee by separation of the condyles is rare, or at 
least is difficult of recognition ; on the other hand, enlargement by effu- 
sion or hemorrhage into the joint is constant. 

The prognosis is serious as regards both the life of the patient and 
the integrity of the joint. Of 26 cases collected by Hennequin 1 7 died, 
3 were amputated, and 16 recovered. The gravity of the injury 
depends mainly upon the implication of the joint and the traumatic 
arthritis excited thereby, which may easily end in suppuration and which 
in any case is very likely to result in more or less stiffness. 

Treatment. — As in other fractures of the femur, continuous extension 
is the most convenient and least painful method of preventing shorten- 
ing of the limb by overriding of the fragments after supracondyloid 
or intercondyloid fracture ; but there is some difference of opinion 
as to the position in which the limb should be kept, whether the knee 
should be completely extended or partly flexed. Those who fear lest 
the lower fragment should be tilted backward by the traction of the 
gastrocnemii muscles prefer the flexed position in order that these may 
be relaxed. The practice, recommended a few years ago, of putting a 
pad in the popliteal space to prevent this tilting by pressure upon the 

1 Des Fractures du Femur, p. 405. 



542 



FRACTURES OF THE FEMUR 



fragment is very objectionable, and I cannot believe that the plan sug- 
gested by Mr. Bryant of dividing the tendo Achillis to accomplish the 
same object can often be necessary. 

If extension in the straight position with weight and pulley fails to 
correct the displacement, the leg may be raised upon pillows so as to flex 
the knee somewhat, or Hodgen's suspended splint may be used. If the 
fracture is impacted or transverse and the tendency to displacement 
slight or absent, the limb may be simply kept on a double inclined plane, 
or in a wire gutter, or even encased in plaster and swung as shown in 
fig. 308, or in plaster splints, or the Bavarian splint. A point of capital 

Fig. 308. 




Plaster splints. A is a wire bent into loops for the purpose of suspension. 



importance in the treatment is to prevent or control inflammation of the 
joint, and the immobilization therefore should be as complete as possible 
for the first two or three weeks, and if the inflammation is acute and 
ankylosis likely to ensue, the knee must be kept almost completely ex- 
tended because the usefulness of the limb will be greatest with the joint 
fixed in that position. 

If suppuration takes place within the joint, the pus must be promptly 
evacuated through a free incision with strict antiseptic precautions, and 
the case treated as a compound fracture. 

Even very grave cases are capable of a favorable termination. An 
Italian laborer, 43 years old, was admitted to the Presbyterian Hospital, 
May, 1881, with a compound fracture of the left femur just above the 
knee, caused by the limb being caught between the pole of a heavy 
wagon and a bank. The wound was on the inner side and large enough 
to admit the finger. I found the bone much splintered and withdrew 
one piece that was completely detached ; it was trough-shaped, half an 
inch long, and comprised nearly half the circumference of the shaft. 
There was lateral motion at the knee-joint and I suspected an intercon- 



FRACTURES AT THE LOWER END OF THE FEMUR 



543 



dyloid fissure. The wound was washed out thoroughly with the car- 
bolic solution, 1 in 20, a drainage tube put in, and a carbolized gauze 
dressing applied ; Buck's extension, and the thigh supported on pillows. 
The temperature did not rise above 100°, and the patient made a good 
recovery and left the hospital with a good joint and limb. 

C. Fracture of either Condyle. — -Fracture of a single condyle may 
be caused by direct violence, as in a fall upon the bent knee, or by avul- 
sion, the force being exerted through one of the lateral ligaments to tear 
off one condyle by bending the leg towards the opposite side. It seems 
not impossible that the effect observed at the elbow of force acting in 
the same direction might also be produced here, and the condyle on the 
side towards which the limb is bent might be broken off by direct pres- 
sure of the head of the tibia upon it. In a case reported by A. H. 
Crosby 1 the fracture was caused by a twist of the leg while the patient, 
a youth of 21 years, was resting his entire weight upon it. 

The specimens of fracture of a single condyle are not numerous, but 
they show that the line may run for a considerable distance upward from 
the interconclyloid notch so that the fragment ter- 
minates above in a long point, or it may turn 
abruptly above the edge of the articular cartilage 
towards the side of the bone, as in figure 309, 
which represents a specimen given to the Dupuy- 
tren Museum by Verneuil ; in this case the perios- 
teum on the inner side and the crucial ligaments 
were untorn and the fragment was ilot displaced. 
(Trelat, loc. cit., p. 69.) 

In a case reported by Dr. Wells, 2 the tibia was 
dislocated outward and backward, and at the au- 
topsy a thick scale of bone was found to have been 
torn from the side of the internal condyle, and to 
remain attached to the ligament. The lea: became 
gangrenous promptly, and death took place on the 
fourth day. In this case the dislocation was the 
essential lesion, and the fracture only an incident. 

The fragment may be displaced upward, or to 
one side, or it may be swung around so as to lie 
partly behind or partly in front of the femur, usu- 
ally the former. As it remains attached to the tibia the first and third 
displacements are indicated by the posture of the leg, the second, which 
is very rare, by the greater breadth of the knee. 

As the displacement is usually slight, and the connections untorn, the 
injury may easily be overlooked, or, if suspected, not recognized with 
certainty. In a case under the care of Gosselin (quoted by Tielat) the 
patient was treated for more than a month for a supposed arthritis of the 
knee ; he grew weaker daily and died of exhaustion. At the autopsy 
the joint was found full of pus and one of the condyles broken. The 




of the internal cou- 
) of the femur. 



1 New Hampshire Journal of .Med., 1857. 

2 Am. Journal Med. Sciences, vol. x., May, 1832, p. 25. 



544 FRACTURES OF THE FEMUR. 

fragments were in exact apposition, but there was no sign of repair. The 
diagnosis must be made upon the localized pain, ecchymosis, loss of func- 
tion, and abnormal mobility and crepitation, recognized by direct man- 
ipulation of the condyle or by moving the leg laterally or in the direc- 
tion of flexion and extension. 

In a case reported to Dr. Hamilton 1 by Dr. Lewis Riggs, a lad 15 
years old had the internal condyle broken off by the kick of a horse ; the 
tibia and fibula were at the same time dislocated inward and upward, 
apparently quitting the articular surface of the external condyle entirely. 
Reduction was accomplished by forcible traction, and the boy recovered 
with a joint that was nearly as good as its fellow. 

The reported cases show a remarkable variety in their course and ter- 
minations. Some patients have recovered without greater reaction than 
would be expected after a simple non-articular fracture ; in others the 
joint has suppurated, and the case has terminated fatally ; in Dr. Crosby's 
case the fragment was removed six months afterwards, by operation, and 
the patient made a complete recovery ; and in a case first seen by Dr. 
Hamilton three months after the injury, the fragment remained ununited 
and could be moved upward half an inch with distinct crepitus and pain 
by flexing the knee. During the next two years the usefulness of the 
limb increased steadily. 

The treatment consists in reduction of such displacement as may exist 
by acting upon the fragment through the lateral ligament and the leg, 
and prevention of its recurrence by keeping the leg fixed in the position 
to which it was brought in making the reduction. As the lateral liga- 
ments are tense when the knee is extended, and relaxed when it is flexed, 
the extended position is the one which gives most security. The objec- 
tion urged by Malgaigne, that it favors ankylosis, is, I think, unimpor- 
tant ; we know that the common cause of ankylosis lies in the severity or 
the prolongation of an arthritis, not in the position in which the joint is 
kept. In the flexed position of the knee a slight displacement upward 
of the fragment could occur easily, and it would certainly pass unrecog- 
nized so long as the position was kept, and would show itself in abduc- 
tion or adduction of the leg as soon as it was extended. I should, there- 
fore, treat such a case in the extended position upon a posterior splint or 
in a plaster bandage with a fenestra if necessary at the joint. After 
three or four weeks the knee might be partly flexed if the fragment had 
lost its mobility, but not otherwise. In short, the condition resembles a 
severe sprain of the joint, and should be similarly treated. I have never 
seen any notable impairment of function follow retention of the limb in 
the extended position for three or four weeks after a severe sprain with 
lateral motion at the joint, while a genu valgum or varum would be a 
serious deformity, and might restrict the usefulness of the limb much 
more than a limitation of flexion would. 

The great importance of complete immobilization is shown by the fail- 
ure of union in some of the cases and the suppuration of the joint in 
others. 

1 Loc. cit., p. 493. 



FRACTURES AT THE LOWER END OF THE FEMUR. 545 

Joints have been safely incised or aspirated of late in recent articular 
fractures to empty them of the effused blood and synovia, and it may be 
that the effusion will render such interference proper in some cases, but 
I should be very loath to undertake it, even by aspiration, unless the 
indication was very positive. On the other hand, it is proper to incise 
the joint, wash it out, and drain it at the earliest possible moment after 
suppuration has begun. 



35 



546 FRACTURES OF THE PATELLA 



CHAPTER XXVI. 

FRACTURES OF THE PATELLA. 

According- to the tables given in Chapter I., fractures of the patella 
represent from one to two per cent, of all fractures. They are much more 
frequent in men than in women, and in middle life than in childhood or 
old age, although Malgaigne maintains that the proportion of fractures 
to population increases with each decade. The youngest of Malgaigne's 
patients was 11 years old, and he knew of no other younger than 17 
years. The youngest patient in the 127 cases collected by Dr. Hamil- 
ton was 5 years old, and the fracture was very different from the usual 
one since only a small piece was broken from the margin of the bone by 
a direct blow ; his next youngest case was 16 years old, and in this also 
the fracture was by direct violence. 

The cause may be direct or indirect, a blow or a fall upon the patella 
or the sudden vigorous contraction of the quadriceps femoris, as in an 
effort to avoid a fall. The statistics that have been collected to show 
the relative frequency of these two varieties vary very widely and are, 
I think, untrustworthy because of the difficulty, or rather the impossi- 
bility, in many cases of recognizing the mode in which the fracture has 
been produced. The patient slips or stumbles, makes an effort to save 
himself, falls, and the patella is found to be broken. He is unable to 
say whether he struck upon the patella or upon the tuberosity of the 
tibia, whether directly in front or upon the side, or, and this I have met 
with several times, he asserts that he fell upon the patella because he 
knows it is broken, and cannot understand that the lesion could have 
been produced in any other way. If the examination is pushed, and 
the question asked, " how do you know it ? " the answer is often " why, 
it must have been so." Unfortunately this sort of reasoning is not con- 
fined to the patients, and some of the statistics are colored by the views 
of those who make them up. 

My own conviction is that the efficient agent in the great majority of 
cases is the contraction of the quadriceps, and the grounds for this belief 
are the numerous cases in which this mode of production can be clearly 
demonstrated, the practical impossibility of producing any but a commi- 
nuted fracture experimentally by direct violence, and the position of the 
patella, which is such that the blow is rarely received upon it in a fall. 

The question whether muscular contraction breaks it by direct trac- 
tion or by bending it over the convexity of the condyles is of purely 
academical interest, and in most cases it cannot be answered positively 
because the position of the bone at the moment of fracture with refer- 
ence to the condyles cannot be known. In a few cases the fracture has 



FRACTURES OF THE PATELLA. 547 

been caused, beyond question, by simple traction without bending or 
cross-strain, as in a case reported by Garreau x in which a second frac- 
ture by muscular action occurred in the upper fragment twelve years 
after the first fracture had healed with a separation of four centimetres 
(If inches). In others it is equally certain that the traction of the lig- 
amentum patellae was inclined somewhat backward from the vertical axis 
of the patella, and that the fracture took place when the limb was in 
nearly complete extension, and the upper part of the patella conse- 
quently resting on the condyles. 

The commonest clinical form of fracture by muscular action is the 
violent effort made by the individual to save himself from falling, an 
effort in which the extensor quadriceps is powerfully contracted. The 
following cases illustrate the different forms. 

Sir Astley Cooper (case 129) tells of a lady who " descending some 
stairs placed her heel near the edge of one of the steps, and was in 
clanger of falling forwards, when throwing her body somewhat backward 
to prevent the fall and to straighten the knee, the patella snapped 
asunder." Ledran, in 1753, reported to the Academie de Chirurgie 
the case of a nun who broke her patella in rising from her knees after 
prayer. In Fielding's case it was broken by the effort to raise a heavy 
basket, and in Boyer's by the effort the patient, a coachman, made to save 
himself from falling backward from his seat. In other cases it has been 
caused by jumping, dancing (on the stage), kicking, in stepping off a 
horse-car in motion, and in trying to avoid a fall while walking. Simul- 
taneous fracture of both patellae by muscular action alone has also 
occurred. Thus, in a case mentioned by Desauli 2 a man who had just 
undergone lithotomy broke both patellae in a convulsive spasm ; and in 
another reported by Marcy, 3 a larg;e heavy woman 38 years old made a 
violent effort to save herself from falling while walking in the street, felt 
" something give way in both knees," and sank to the ground. On ex- 
amination both patellae were found to be fractured transversely near the 
middle, the upper fragment lying two inches above the lower one. Valette 
tells of a porter who slipped while carrying a heavy burden up a stair- 
case, made an effort to save himself, and fractured both patellae ; and 
Johnston 4 tells of a woman 33 years old who broke both by tripping upon 
a door-mat. "In the act of falling forward she distinctly heard a crack 
and felt something give w T ay ;" the separation in this case was three- 
fourths of an inch. A man 5 while jumping in leap-frog felt as if he had 
received a blow on the legs and fell ; he had sustained a transvere fracture 
of each patella. 

In a few cases there is reason to think that a blow upon the bone has 
cracked it or originated some process in it by which its complete fracture 
by muscular action shortly afterward was made easy. 

Pathological Anatomy. — In the great majority of cases, it may per- 
haps be said in all in which direct violence is not certainly the cause, 
the fracture is transverse or slightly oblique, and usually at or just below 

1 Revue Medico-Chirurg., 1853, p. 375. 

2 GEuvres Chirurgicales, 3d ed., vol. i. p. 252. 

3 Boston Med. and Surg. Journal, vol. xci., 1874, p. 362. 

4 Lancet, 1873, vol. ii. p. 661. 

5 Med. Times and Gazette, Oct. 9, 18S0. 



518 



FRACTURES OF THE PATELLA 



Fig. 310. 



the middle of the bone. In the cases collected by Dr. Hamilton 22 were 
recorded as below, 7 above, and 16 at the middle. The only instance of 
incomplete fracture of which I have knowledge is 
a specimen, apparently without history, in the 
Musee Dupuytren (fig. 310). It is described by 
Berger 1 as a transverse fracture that has largely 
interested the articular surface of the patella and 
its cartilage, with a separation at the centre of six 
millimetres. There is no trace of fracture on the 
anterior surface. There is some doubt, however, 
as to the exact character of this specimen, andsome 
reason to think that it is the same as one represented 
by Malgaigne in his Atlas (plate 14, figs. 2 and 3) 
as a specimen of bony union after complete fracture. 
Poland 2 quotes two cases of fracture without 
division of the cartilage, one a gunshot fracture reported by McLeod, 
the other deserving to be classed as a wound of the bone rather than 
as a fracture, for the patient fell and struck his knee against the edge of 
a cutlass ; the cut is said to have extended through the bone but not 
through the cartilage. Poland made some experiments in connection 
with these two cases and found he could divide the patella completely 
with a chisel and still leave the cartilage untorn. 

Vertical fracture of the patella (fig. 311) is not very rare and has 




Incomplete fracture of the 
patella. Articular surface. 



Fig. 311. 



Fig-. 312. 




*m$:t v ' 




Vertical fracture of the patella. (Holmes.) 



Oblique fracture of the pateli; 



always been the result of direct violence. The fragments may be of 
equal size, or one may be much larger than the other. With these may 
also be classed oblique fractures caused by direct violence. 

Multiple or comminuted fractures (fig. 313) are always due to direct 
violence, and are characterized by their slight displacement and their 
tendency to bony union. It has been noticed, however, that when there 
were two main lines of fracture, one transverse and the other vertical, 



1 Diet. Encyclopedique des Sc. Med., art. Rotule, p. 257. 

2 Medioo-Cliirurg. Trans., 1870, p. 49. 




FRACTURES OF THE PATELLA. 549 

the fragments lying above the transverse fracture, and those lying below 
it would each unite by bone, but the union between the two pairs or the 
two groups would be fibrous and long. 

The displacement after transverse fracture is ordinarily well marked, 
and its degree is modified by the extent to which the overlying fibrous 
tissues and the aponeurosis on each side are 
torn. Berger refers to two specimens in the Fig. 313. 

Musee Dupuytren in one of which the fibrous 
covering in front is completely preserved, and 
the fracture, which is exactly transverse and 
in the centre of the bone, is there indicated 
only by a slight depression, while it is very 
apparent on the articular surface ; the patient 
walked to the hospital. In the other there is 
fibrous union, and the separation is apparent 
only on the articular surface and especially at 
its outer border. 

The displacement is most marked in those comminuted fracture of the 

fractures in which the muscles have been Patella. B on y uuioil Exuber- 

1 _ ant callus at several poiuts. 

vigorously contracted at the moment or the (Gurit.) 
accident in the effort either to avoid a fall or 

to do some act requiring the exercise of considerable force. Under such 
circumstances the separation is usually an inch or more. It is due, of 
course, in great part to the retraction of the quadriceps which draws the 
upper fragment upward, but not entirely so, for from the moment that 
the joint becomes at all distended by an effusion of either blood or 
synovia into it, the fragments are pressed apart by the liquid to meet 
the need of more space. As a result of this it also follows that the 
separation grows less as the effusion diminishes. 

A third cause, which acts less promptly, is the retraction of the liga- 
mentum patellae. It was pointed out long ago that after union with much 
separation of the fragments the ligament was much shorter than its fellow 
of the opposite side ; in one of Malgaigne's 1 cases it was shortened one 
half, measuring only three centimetres. Gerock, 2 basing the statement 
on a large number of exact measurements, claims that it is the essential 
cause of the separation. It seems more probable that it is one of the 
consequences. 

The other displacements are more readily recognizable after union. 
They are lateral displacement and angular displacement, the angle point- 
ing forward, backward, or to one side. Lateral angular displacement 
appears to be commonly the result of uneven stretching of the fibrous 
union after the patient begins to use the limb ; anterior angular displace- 
ment is not only produced by the pressure of pads or bandages above 
and below the fragments when the latter are in contact, or nearly so, 
but it is also the inevitable effect of separation by distension and may go 
so far that the broken surface of the lower fragment is turned directly for- 
ward and unites with the soft parts overlying the gap, as in figure 314 ; 

3 Atlas, Plate 14, fig. 4, and p. 17. 

2 Inaug. Dissertation, Tubingen, 1872, quoted by Berger. 



550 



FRACTURES OF THE PATELLA. 



Fig. 314. 



\ 



A 



M 



I 



: 



,9 



w 



Fibrous union with great 
separation, after fracture 
of the patella. The band 
adheres to the broken sur- 
face of the lower fragment. 
(Holmes's Syst.) 



and in at least one specimen, in the Muse*e Dupuy- 
tren, the articular surface of the lower fragment is 
united to the broken surface of the upper one, the 
former presenting an angular displacement of 90°. 

Symptoms. — In fractures by muscular action, 
with or without a fall, a sharp crack may be heard 
and the patient is usually unable to use his limb. 
In a few cases he has walked, and, indeed, in most 
it is possible to walk backward, keeping the knee 
extended by the pressure of the heel on the ground, 
or even to walk forward if the uninjured limb is ad- 
vanced and the other swung up to but not beyond it. 

The knee becomes promptly swollen by an effu- 
sion of blood or synovia into it and by tumefaction 
of the soft parts, especially if a blow has been re- 
ceived upon it, and the two fragments, separated 
usually by a well-marked interval, can be made out 
and their independent mobility recognized. This 
mobility may be very slight if the fragments are 
close together, but then crepitation may perhaps be 
perceived. 

The subjective symptoms are moderate pain when 
the limb is at rest, increased by movement, and in- 
ability to extend the leg or to raise the heel from 
the bed. It must be remembered that in rare, en- 
tirely exceptional cases the fibrous covering of the 
bone may remain untorn and constitute a sufficient 
the fragments to make a limited use of the limb 



connection between 
possible. 

In vertical or comminuted fractures the signs recognized by palpation 
will vary in accordance with the differences in the lines of the fracture, 
and in the former active extension will be prevented only by the pain 
attending the effort. 

Course and Terminations. — The arthritis which follows the fracture 
is usually moderate and subsides within the first fortnight. When the 
swelling forms slowly by exudation from the synovial sac the blood from 
the fracture mixes with it evenly, but when it forms immediately it 
is composed mainly of blood which forms a solid homogeneous clot ad- 
herent to the surfaces of fracture. The swelling diminishes as the 
arthritis grows less acute and as the synovia and serum are reabsorbed, 
and in all probability the blood clot disintegrates under the action of the 
liquid in which it bathes, and disappears as it does under similar condi- 
tions elsewhere. Sometimes the prepatellar bursa becomes distended 
either by an effusion poured out within itself, the result of direct violence, 
or by the escape into it through the fracture of the effusion formed within 
the joint. 

The surfaces of fracture and the torn tissues form granulations in the 
usual manner, and the great differences in the result, differences in the 
composition and length of the bond between the fragments, depend upon 



FRACTURES OF THE PATELLA. 



551 



the proximity of the fragments to each other. If the fractured surfaces 
are in close contact the granulations unite and constitute a close fibrous 




Fig. 316. 



H 



WW 

Bony union of the patella. (Bryant.) 

union or a bony one (fig. 315) ; if ? on the other hand, 
they are at some distance from each other the evolution 
of the new tissue does not pass beyond the fibrous stage, 
and the union is by a thick fibrous band of greater or 
less length (fig. 316) ; or the formation of tissue is very 
scanty and the fragments are held together only by the 
overlying soft parts more or less condensed by the irrita- 
tion following the injury (fig. 314). In the latter case 
the tilting of the lower fragment brings its broken surface 
into contact and union with the overlying parts. The 
length of this fibrous band varies in different cases be- 
tween a few lines and several (five or six) inches, and some- 
times its length is increased notably by flexing the knee. 

Hypertrophy of the fragments, occurring during and subsequent to 
repair, is frequently noticed, and sometimes also the production of irregu- 
lar bony points from the fractured surfaces or of isolated nodules within 
the connecting fibrous band. 

Even when the union is so close that the fragments show no indepen- 
dent mobility it is impossible to say at first that the union is bony. The 
test is found in time and use, and it is cprite common to see a gap 
which is very slight at the time treatment ends increase to the length of 
half an inch or even more in the course of a few months ; and this sepa- 
ration may be greater on one side than on the other, as in a case re- 
ported by Coaie, 1 in which there was no recognizable gap at the end of 
treatment, but ten years afterwards there was separation to the distance 
of an inch on the outer side and one-eighth of an inch on the inner. Dr. 
Edward T. .Caswell 2 reports a case in which after four years the separa- 
tion is not more than one-eighth of an inch, although it was one and a 
half inches at the time of the accident. In such a case it might reason- 
ably be supposed that the union was bony, and yet the same surgeon 
quotes a cast 3 to show how deceptive this appearance may be. " The 



1 Boston Med. and Surg. Journal, vol. liv. p. 402. 

2 Holmes's System of Surgery, Am. ed., vol. i. p. 952. 

3 Boston Med. and Surg. Journal, May 2, 1878, p. 57$ 



552 



FRACTURES OF THE PATELLA. 



union was so very close and firm that after removal, with all the force 
that could be used, not the slightest motion between the fragments could 
be felt, and it would have been regarded as a bony union if it had not been 
either sawed or macerated. Three longitudinal sections, however, were 
made through the bone, and it was proved, so far as these would show, 
that at no points were the fragments united by bone." Berger 1 reports 
a similar case under his own care, in which, ten years after the accident, 
" the patella seemed identical with its fellow, and only a slight trans- 
verse groove marked the seat of the former fracture. No abnormal 
mobility could be recognized on handling the fragments, and the callus 
might have been thought to be bony, but on relaxing the quadriceps 
completely by extending the knee and flexing the thigh on the pelvis 
slight mobility could be plainly detected. 

These two cases show with how much reserve assertions of recovery 
with bony union should be received. Clinical proof of such union is 
almost impossible. 

That bony union of a simple transverse fracture can and does occur 
has been demonstrated anatomically. Fig. 315 represents a specimen 
of unknown history, but apparently of such union, preserved in Guy's 
Hospital Museum, and described by W. King in the Guy's Reports, 
Series 1, Vol. VI. Berger figures another preserved in the Musee 
Dupuytren (fig. 317), and quotes a third from Gerock, in which the 
separation, nevertheless, was nine millimetres. The specimen figured 
by Malgaigne (figs. 318 and 319) was thought by Houel, the Director 



Fig. 317. 



Fig. 318. 



Fig. 319. 




—A 




"ife 



w 



Bony union after fracture 
of the patella. Specimen 201 
of the Musee Dupuytren. 



Fracture of patella. 
Articular surface. 




Fracture of patella. Anterior 
surface (hony union). 



of the Dupuytren Museum, to be one preserved in that museum, and 
considered by him as incomplete fracture, not as bony union. Malgaigne 
quotes from Camper a case in which a bony bridge united the two main 
fragments and an intermediate splinter in the median line, while the 



Loc. cit., p. 267. 




FRACTURES OF THE PATELLA. 553 

union on the sides was fibrous ; and there are quite a number of speci- 
mens in existence showing the formation of bony stalactites of greater 
or less length, and always, I believe, upon the lower fragment. 

The length of time necessary to consolidation cannot be positively' 
determined, because of the tendency to the elongation of the fibrous 
band under use, a tendency which seems to exist in some cases for years, 
and in others for only a few weeks. Whether or not this difference 
depends solely upon the length of time during which the limb is kept at 
rest immediately" after the injury I have no means of knowing, but it is 
certain that early use of the joint favors the lengthening. 

Rupture of the band and iterative fracture of the bone have been 
frequently observed at longer or shorter intervals after the original acci- 
dent. Mr. Bryant refers to a case in his own experience in which one 
patella had been broken twice and the other three times, and Moore 
mentioned a similar case in the discussion on Poland's paper [Brit. Med. 
Journal, 1870, i. p. 91), in which suppuration occurred after the third 
fracture, and caused death. 

Fig. 320 represents a specimen Flg * 320 ' 

of supposed multiple fracture 
from Bryant's collection. 

In several cases this rupture 

.. . .. , ., l . Multiple fracture of the patella. (Bryant) 

of the band has caused at the 

same time a wound of the integuments, and opened the joint. Poland 
quotes three such cases : one reported by Chas. Bell and treated by 
amputation; another by Dr. Croker King, in which the injury was 
caused by having the leg forcibly bent in a fall five months after the first 
fracture, the patient recovering in thirty-three days ; and one by Seutin 
after an interval of seven months — amputation was done four months 
later. Erskine Mason 1 reported a similar case to the N. Y. Pathologi- 
cal Society ; the accident occurred after an interval of a year, the sepa- 
ration being about three-fourths of an inch, and the joint quite stiff. The 
patient fell with the leg bent under him ; amputation was done, and he 
died. Roberts 2 mentions briefly a similar case ; the patient was a woman, 
the knee stiff, and the cause of the rupture a fall. The patient recov- 
ered "with some separation of the fragments and a partially stiff joint." 

The occurrence of this accident is evidently favored by stiffness of the 
joint, and the mechanism appears to be the tearing away of the lower 
fragment by the violent flexing of the leg, the upper fragment being held 
in place by the contraction of the quadriceps and the adhesions of new 
formation between it and the condyles. The laceration of the overlying 
soft parts is the consequence of their condensation and adhesion to the 
fragments. 

Compound fractures, in which the wound of the soft parts was caused 
in the same manner, have been reported by Poland (Medico- Chirurgical 
Transactions, 1870, p. 49) and by Pelletan. In that of the former the 
patient wounded the skin over the patella by a fall ; eight weeks later, 
when the wound had almost healed, he broke the patella in trying to 

1 N. Y. Med. Record, 1875, p. 211. 

2 Bryant's Surgery, 3d Am. ed., p. 853. 



554 



FRACTURES OF THE PATELLA. 



save himself from falling, the cicatrix in the skin tore open, and the 
fracture thus became compound. The joint suppurated, and resort was 
had to amputation. 

- In a compound comminuted fracture reported by Schede 1 two-thirds of 
the bone became necrosed ; the joint was drained, and the bone was 
reproduced. At the time of the report the patient was able to walk, 
and there was some motion in the joint. 

The injury may result in more or less loss of function of the limb by 
rigidity of the joint or incompleteness of the repair, and this loss may 
persist for a longer or shorter time. Rigidity is always well marked 
when the limb is first taken out of the splints, and its degree and per- 
sistence seem to depend more upon the severity of the arthritis set up 
by the fracture than upon the length of time during which the limb has 
been immobolized, or the age of the patient. It is not safe to attempt to 
overcome the rigidity by forcible flexion of the knee, lest the band 
uniting the fragments should be ruptured or stretched ; it must be left to 
time and ordinary use of the limb. 

The disability due to the failure to obtain close bony union is ordi- 
narily slight, and not noticeable in the common everyday use of the 
limb, yet its degree varies by no means directly with the length of the 
band that unites the fragment. Quite a number of cases have been 
reported in which the limb was very useful, notwithstanding a separation 
of from two to five inches, and in the case represented in fig. 321, which 



Fig. 321. 




Extreme separation of the fragments after fracture of the patella. (From a photograph ) 

was under my care in Bellevue Hospital, with fracture of the other 
patella, four years after the accident to the one shown in the cut, the 
patient walked easily and securely, although there was separation to the 
distance of 4J inches when the limb was extended, and although there 
was no power of active extension, except to a very slight degree through 

1 Deutsche Gesellschaft fur Cliirurgie, 3d Congress, 1874, p. 185. 



FRACTURES OF THE PATELLA. 555 

the aponeurotic attachments in the position of- nearly complete extension. 
All writers mention similar cases. On the other hand, the disability has 
been almost complete in a few instances in which the union was quite 
close, but it is not clear that it was due solely to the length or weakness 
of the bond of union. 

The weakening when present is shown in both the force and the range 
of active extension. The actual strength of the limb is found to be Less, 
and in the more marked cases active extension is possible only when the 
limb is nearly extended. Some patients are unable to raise the heel 
from the bed without some previous flexion of the knee, or, if standing, 
to carry the limb forward without bending the knee. It must be remem- 
bered, however, that this disability, even when extensive, does not 
always show itself permanently in the ordinary use of the limb, and the 
patients are able to walk without limping. It appears when they are 
called upon for a greater effort, as in running, carrying a heavy burden, 
or going up or down stairs. Singular as it may seem, it is easier for 
such an individual to ascend a staircase or an incline than to descend it. 

When the distance between the fragments can be increased by flexion 
of the knee it proves that almost the w T hole of the quadriceps has been 
rendered useless for the extension of the leg, and that such power of 
active extension as still exists is exerted mainly through the lower frag- 
ment alone by the fibres of the vasti that are attached directly to it, and 
perhaps in some manner by the aponeurotic attachments of the upper 
fragment. The simple lengthening of the tendon (patella) ought not, 
theoretically, to diminish the power of extension any more than the 
equivalent lengthening produced so often by shortening of the thigh after 
fracture ; at the most it should weaken it only at and near the position 
of complete extension ; but it is found, on the contrary, that in the fee- 
blest cases that is the only portion of the range of motion in which 
active extension is possible. The cause, therefore, must be sought, not 
in the lengthening of the cord, but in the creation of attachments be- 
tween the upper fragment and the femur, which prevent the former from 
moving up the thigh when the quadriceps contracts, and thus effectually 
divert its action from the tibia. 

A compound fracture is, of course, much more serious than a simple 
one, endangering the life of the patient as well as the integrity of the 
joint. The statistics are rather scanty, and are open to the objection 
which applies to all such lists made up of reported cases, that the pro- 
portion of favorable cases reported is larger than that of the unfavorable 
ones. On the other hand, the modern methods of treatment of wounded 
joints yield much better results, and there is good reason to hope that 
the percentage of success will be actually even higher in the future than 
that of the partial statistics of the past. Those statistics are as follows : 
Poland (loc. cit.) collected 69 cases, in 40 of which the fracture was 
caused by a fall or a blow with a blunt instrument. Bouchard and Ber- 
ger collected 29 others. Of these 69 (40 + 29) cases 7 were treated 
by amputation ; of the remaining 62, 18 died and 44 recovered. In IT 
of these 44, the functions of the joint were preserved almost unim- 
paired, in 11 the range of motion was limited, and in 16 there was com- 
plete ankylosis. In 14 of the 17 the joint did not suppurate ; in several 



556 FRACTURES OF THE PATELLA. 

of those that terminated in ankylosis the suppuration was profuse and 
the life of the patient threatened seriously. 

Treatment. — The objects of treatment are twofold : to secure close 
union of the fragments, and to prevent or control inflammation of the 
joint and the adjacent tissues. The multiplicity 1 of the methods prepared 
to meet the first indication points out only too clearly the difficulty of 
accomplishing it and the insufficiency or unfitness of the means proposed. 
The small size of the fragments and the convexity of the surface of the 
condyles upon which they rest when the limb is extended, make it diffi- 
cult to act upon them directly without creating some angular displace- 
ment ; they tilt forward at the line of fracture if they are brought 
together, and only too often it is found that the means used to hold them 
together after the adjustment has been made fail to accomplish their pur- 
pose. The different methods may be roughly classed as seeking to act : 
1st, by simply relaxing the extensor muscles, keeping the knee extended 
and the hip somewhat flexed ; 2d, immobilization of the fragments by a 
firm ring or mould inclosing them ; 3d, by pressure, fixed or elastic, upon 
the fragments or the adjoining soft parts in opposite directions ; 4th, by 
direct action upon the fragments by metal points ; and, in addition, 
measures, considered the most important of all by some, to prevent or 
subdue the arthritis and to hasten the absorption of the effusion, meas- 
ures which may be used in connection with or previous to the employment 
of the mechanical ones already mentioned. 

The methods of local treatment usually employed under other circum- 
stances to control inflammation or promote absorption of the effusion 
may be usefully employed here ; cooling lotions, lead and opium, the 
ice-bag, irrigation, and poultices, are the ones in most frequent use. 
Guy on recommends blistering. Aspiration of the joint, to remove its 
increased contents and thus favor coaptation, was proposed and practised 
about 1870, but was not received with much favor, because of the risk 
of provoking suppuration of the joint thereby. A successful case of its 
use, by Labbe, was followed by another by Dubrueil, 2 in which the punc- 
ture suppurated and led to a purulent arthritis ; the final result was not 
reported. 

Of late the plan has been again employed in connection with antisep- 
tics. Schedt 3 punctures the joint to remove the blood and synovia, 
washes it out with a three per cent, solution of carbolic acid, continuing 
the washing until the water returns clear, covers the puncture with an- 
tiseptic cotton, binds it down and fixes the fragments together with a 
" testudo" 4 of adhesive plaster over which he applies a flannel bandage 
and then a dressing of plaster of Paris. He renews the entire dressing 
during or at the end of the first week, and then again once or twice at 
intervals of a week or two in order to make sure of the adjustment. 

1 Berger says lie made a list of ninety-one different methods of treatment, exclud- 
ing five or six concerning which he was unable to obtain sufficient details. 

2 Bull, de la Societe de Chirurgie, Oct. 1872, p. 438. 

3 Centralblatt fur Chirurgie, 1877, p 657. 

4 This is composed of many long narrow strips of adhesive plaster applied above 
and below the fragments, so that they reach from the middle of the back part of the 
thigh to the middle of the calf, crossing in front of the knee and pressing the frag- 
ments together. 



FRACTURES OF THE PATELLA. 



557 



He reports six cases in which he used this plan with good results. 
The injection causes no pain, it is followed by an effusion into the joint, 
and it is this effusion and its absorption which render the readjustment 
necessary. 

Corroborative testimony as to the value and safety of the method is 
furnished by the success following the similar treatment of compound 
fractures and of operations for the relief of ununited fracture or of frac- 
ture with separation of the fragments. I have no experience with it, 
but I certainly should not employ it in any case in which the effusion 
was of moderate size and in which the fragments could be brought 
together. There are other methods of avoiding excessive reaction and 
promoting absorption which involve less risk. 1 

A description of all the methods recommended to keep the fragments 
in contact is not required. The following have been selected as the 
ones most deserving mention. 

Dr. Agnew 2 uses a splint which is " a piece of pine board somewhat 
convex longitudinally on the upper surface, thirty inches long, and five 
inches wide at one end, tapering to four inches at the other. On each 
side, a short distance above and below the middle of the board, are to 
be bored two holes, into which are fitted four pegs with square heads 
(fig. 322). This splint must be well padded and placed under the 



Fig. 322. 




Agnew's splint for fracture of the patella. 

thio-h and the leg, the limb being at the same time moderately elevated. 
Below the knee and the lower fragment are next to be applied, partially 
overlapping each other, two or three strips of adhesive plaster, each three- 
quarters of an inch wide and thirteen inches long. These strips are 
brought together at their extremities and wrapped round the upper pegs. 
This°secures in position the lower fragment. Five strips of plaster of 
like length and width are next applied three or four inches above the 
knee, descending toward the joint, each strip overlapping one-third of 
the preceding one. Bringing the ends of the plaster together they are 
to be wound around the lower pin, when, by screwing or twisting the 
pegs of the two sides, the lower fragment will be brought into near ap- 
position with the upper. To prevent the broken surfaces from tilting 
forward, a broad strip of plaster may be drawn over the line of approxi- 

1 Disastrous consequences have followed this treatment in some cases, death by 
carbolic acid poisoning, suppuration of the joint, and secondary amputation. See 
Fowler in Annals of Anatomy and Surgery, June, 1882, and Wyeth in .Med. Record, 
June 3, 1882. 

2 Surgery, vol. i. p. 974. 



558 



FRACTURES OF THE PATELLA 



mation and fastened to the splint below. A roller is now applied above 
and below, which secures the thigh and leg to the splint (fig. 323). 




gnew's splint applied. 



As the swelling subsides all that is necessary to maintain the adjustment 
is to tighten the strips by screwing up the pegs to which they are fas- 
tened. By this plan the removal of the dressing is rendered unnecessary 
until the cure is complete. Between the third and fourth weeks the 
strips may be separated from the pins, the knee gently moved so as to 
overcome stiffening, and the dressing again adjusted. This process 
should be repeated every five or six days, or until the fifth week, when 
the splint may be laid aside and the patient be placed on crutches." 

Dr. Hamilton's 1 method of treatment is as follows; the limb is ex- 
tended, the foot elevated about six inches, and a moulded splint made of 
leather or other light firm material fitted to the back of the thigh and 
leg ; it should extend from above the middle of the thigh to two or 
three inches above the heel. The splint is then removed and fitted with 
a covering of cotton cloth, with the double object of protecting the skin 
and of supplying a basis to which the turns of the roller bandages after- 
wards applied can be stitched (fig. 324). 



Fm. 324. 




Hamilton's dressing for fiacture of the patella. The final tui'ns of the roller in front of the knee 

are not shown in the cut. 

The splint is then fastened to the limb with a roller bandage, the 
region of the knee and about three inches on each side being left uncov- 
ered. Then " while an assistant approximates the fragments with his 



1 Loc. cit., p. 



FRACTURES OF THE PATELLA. 559 

fingers, the surgeon makes two or three turns, with a third roller around 
the limb and splint, close above the knee ; after which the roller descends 
below the knee, and an equal number of circular turns are made close 
below the lower fragment of the patella ; and finally a succession of 
oblique and circular turns are made above and below the fragments, 
which turns are to approach each other in front until the whole of the 
patella is covered — the last turns being again circular. The dressing 
now being completed, the rollers are carefully stitched to the cover of 
the splint throughout its whole length, on both sides," and the foot kept 
elevated. 

" On the second or third day the swelling of the knee will be found, 
probably, to have subsided somewhat, and the oblique turns of the ban- 
dage from above and below the patella will need to be tightened. This 
will be done by overstitching them with strong thread, taking care to 
do this on both sides and so far back that the doubling of the cloth will 
not be over the sides of the exposed portions of the limb. The same 
thing may require to be done every day, or every second or third day, 
for two or four weeks." 

After the fourth week he makes gentle passive motion daily and 
allows the patient to go about on crutches, but requires him to wear a 
similar but shorter splint for three or four months longer. 

Mr. Bryant advises against any pressure upon the bone and says he 
has known secondary suppuration, necrosis, and joint complications of a 
serious nature to be caused by it. He also advises that no dressing 
should be applied during the first few days or until after all inflamma- 
tory action has subsided. 

Immovable plaster or starch dressings should not be used, at least not 
without a large fenestra over the front of the knee through which the 
position of the fragments can be noted and pressure made upon them if 
necessary. The best results I have obtained have been by a light plas- 
ter of Paris bandage extending from the upper third of the thigh to the 
ankle and reinforced by a strip of metal or wood • included in it poste- 




riorly, with a fenestra eight or ten inches long and seven or eight inches 
wide over the front of the knee. On each side of the dressing above 
and below the fenestra are fixed pieces of w T ire or hooks for the attach- 
ment of rubber bands which are passed above and below the fragments 
so as to press the lower one upward and the upper one downward. The 
skin is protected by strips of lint or a thin layer of cotton, and the trac- 
tion of the rubbers is diminished or increased from time to time accord- 



560 



FRACTURES OF THE PATELLA. 



ing to the condition of the skin. The principle underlying this method 
is found in many others that have been in use for many years, one of 
the earlier forms of which, used by Laugier, is represented in fig. 325. 
Its principal merits are the ready inspection of the parts which it per- 
mits and the modification of the pressure to suit the needs of the case 
and the condition of the skin. 

A similar method of drawing down the upper fragment by an elastic 
or yielding traction is found in the various plans by which the traction 
is applied to the skin of the anterior surface of the thigh by strips of ad- 
hesive plaster. A strip cut somewhat in the shape of the letter (J? but; 
with the curved part very much broader than the sides, is fastened upon 
the thigh above the patella in such a manner that its sides pass down on 
each side of the leg and are attached to a weight by a cord passing over 
a pulley at the foot of the bed or to an India-rubber u accumulator" as 
shown in figure 326. Through the adhesion of the plaster to the skin 

Fig. 326. 




Aecumulat 



Treatment of fracture of the patella by elastic traction. 



Fig. 327. 



of the anterior surface of the thigh the quadriceps is drawn down and 
with it, of course, the upper fragment. Moderate pressure by a band- 
age, elastic or inelastic, upon the lower fragment aids to keep the two in 
contact. I think it would be equally efficient to tie the cords attached 
to the ends of the plaster about the foot-piece and to tighten them when- 
ever needed. 

Malgaigne sought to act directly upon the fragments by a pair of 
double hooks adjustable upon each other (fig. 3^7). The points are 

passed through the skin and engaged, 
the one pair at the upper part of the 
upper fragment, and the other at the 
lower part of the lower one, and then 
brought together by means of the 
screw until the fragments are accu- 
rately coaptated. The objections to 
the method seem to be mainly senti- 
mental, the dislike to puncturing the 
Maigaigne's hooks. skin and causing pain ; but in at least 

one instance a fatal erysipelas has 
originated in the punctures. The probability of the recurrence of such 
an accident has been greatly diminished by the improvement in the 
hygienic condition of our hospitals, and in our methods of treating 
wounds ; but still the possibility is perhaps a legitimate objection to the 
method. The hooks must be inserted with a good deal of force, so that 




FRACTURES OF THE PATELLA 



561 



their points will penetrate to the bone and thus Fi S- 328 - 

insure the fixity which is the only excuse for 
their employment, and which may be easily lost 
if the hooks are engaged only in the tendon. 

Dr. Levis has modified the hooks by separat- 
ing them into two independent pairs, which may 
be placed obliquely (fig. 328). 

Trelat modified it by fixing the points of the 
hooks in pieces of gutta percha moulded to the 
limb above and below the fracture (fig. 329) ; 
and this again was modified by Verneuil and 
Le Fort, who substituted an elastic cord for the 
hooks, the former passing it through holes made 
close to the edge of the gutta percha plates, the 
other passing it about hooks imbedded in the 
plates while they were heated in the flame of a 
candle (fig. 330). 

Kocher 1 has tried to bring and keep the frag- 
ments together by passing a strong silver wire 

vertically through the joint under them, from below upwards, by means 
of a curved needle, and twisting its ends together firmly in front. He 




Levis's modification in place. 




Tr61at's dressing for fracture of the patella. 

has done this with antiseptic precautions in two cases of simple frac- 
ture, but the result — notable diminution of the separation with fibrous 
union — is not sufficiently good to outweigh the mistrust which the proposal 
excites, although in neither case was there inflammatory reaction or pain. 
In compound fractures the published experience of the last few years 
indicates plainly the method that should be pursued. If the wound is 
small, the injury very recent, and the adjoining soft parts not bruised or 
lacerated, it may be proper to try to convert the fracture immediately 
into a simple one by an occludent dressing ; but if such an attempt should 
be inappropriate or should fail the joint should be washed out very 
thoroughly with a five per cent, solution of carbolic acid, a short drain- 
age tube should be placed on each side, extending of course into the 
joint, an antiseptic dressing placed over all, and the limb fixed in the 



36 



1 Centralblatt fur Chirurgie, 1880, p. 321, 



562 FRACTURES OF THE PATELLA. 

extended position upon a posterior or a bracketed splint. If all goes 
well the drainage tubes should be removed during the first week. 

Fig. 330. 




Le Fort's dressing for fracture of the patella. 

In a case reported by Dr. Fitzau 1 a comminuted compound fracture was 
caused by the kick of a horse. It was treated in the manner above de- 
scribed, and on the twenty -seventh day when the sixth Lister dressing was 
removed the wound was small and superficial and the joint entirely free 
from swelling and pain, and at the end of two months the joint was 
almost as good as before the accident. 

In a case mentioned by Dr. Maclaren, 2 a man was brought into the hos- 
pital thirty-six hours after having received a compound transverse fracture 
of the patella by direct violence. The wound was two inches long, was 
smelling badly, and was discharging sanious fluid. It was irrigated for 
two hours with a five per cent, carbolic solution and then dressed with 
the gauze. Thirteen days afterwards the wound had become superficial, 
and the joint free from inflammation, and very shortly afterwards the 
dressings were discontiuued and an extension apparatus applied to bring 
the fragments together. 

Ununited Fracture. — The absence of dangerous complications and 
the successes obtained in such cases and in similar ones involving other 
joints have led some surgeons to cut down upon ununited fractures of 
the patella and even upon recent ones in order to wire the fragments 
together. 

A case of refracture with separation of 1\ inches in a man 27 years 
old, treated successfully in this manner with supposed bony union and 
good use of the joint, was reported to the Medical Society of London by 
Mr. R. Bell, 3 and at the following meeting of the society two cases of 
recent fracture thus treated were reported by Mr. Rose, 4 in each of 
which the operation was done on the nineteenth day. 

In Mr. Bell's case the fracture took place September 24, 1878, the 
refracture January 31, 1879, and the operation in the following July. 

1 Centralblatt fur Chirurgie, 1881, p. 749. 

2 Lancet, January 31, 1880, p. 160. 

3 Lancet, November 1, 1879, p. 657. 

4 Lancet, November 22, 1879, p. 767. 



FRACTURES OP THE PATELLA. 563 

It was found necessary to divide the lateral attachments of the patella 
and the whole of the rectus femoris and tendon subcutaneously three 
inches above the upper margin of the bone before the fragments could be 
brought together. The drainage tubes were removed in the fourth week, 
and the silver wires after 2 J months. When shown to the Society in the 
following October, the patient could walk without a cane, and could go 
up and down stairs, and the joint was daily becoming more useful. Its 
range of motion was then about 60°. 

In Mr. Rose's cases the bone was exposed by a longitudinal incision 
in the median line, its surfaces freshened, the lateral attachments freed 
a little, and the pieces wired together at two points, the wires running 
close to the articular surface, but not through it. He drained with horse- 
hair and took out the wires in the sixth week. 

In the discussion that followed the report of these cases Mr. Lister 
said the operation had been first done by Dr. Hector Cameron, of 
Glasgow. 

Schneider 1 collected nine cases thus treated, besides one of his own ; 
in five the fracture "was recent, in five old and presumably ununited. In 
eight good union was obtained, with a movable joint ; in two the joint 
suppurated and ankylosis resulted. 

1 Arehiv fur Klin. Cliirnrgie, 1881, vol. xxvi. 



56 i FRACTURES OF THE BONES OF THE LEG. 



CHAPTER XXVII. 

FRACTURES OF THE BONES OF THE LEG. 

According to the statistics of the London Hospital for 35 years (page 
35) fractures of the leg constitute 16 per cent, of all fractures, and are 
second in order of frequency, those of the forearm being first, 18 per 
cent., those of the ribs third, 15,9 per cent. The more detailed statistics 
collected by Gurlt (Table I. page 34) show a total of 711 fractures, of 
which 461 were of the leg, that is, of both bones, 107 of the tibia, 108 
of the fibula, and 32 of the malleoli. This distinction of the malleoli in 
the classification was made in only one-third of the cases that compose 
the table. The proportions in another set of statistics, quoted by Pon- 
cet, 1 are 1723 of both bones, 360 of the fibula, and 232 of the tibia. Of 
2315 cases in the Pennsylvania Hospital 2 1441 were of both bones, 437 
of the tibia, and 437 of the fibula ; and according to the same tables it 
appears that in 246 fractures of the tibia 120 were in the lower third, 
81 in the middle third, and 45 in the upper third ; that in 252 fractures 
of the fibula 210 were in the lower and 26 in the middle third. When 
both bones are broken the fibula is usually broken at a higher level than 
the tibia. 

Examination of the statistics with reference to the age of the patients 
shows that infancy and childhood are almost exempt, and that the maxi- 
mum of frequency is found between the ages of 30 and 60 years, those 
three decades, according to Malgaigne, furnishing equal numbers. 

The varieties of fracture and the causes are those which pertain to 
other long bones, the different portions of the bone, however, presenting 
the different varieties in different degrees ; and this fact, taken in con- 
nection with the great clinical differences between the fractures of the 
different portions, justifies, I think, a departure from the usual method 
of classification and description. The usual plan of describing these 
fractures in three groups, those involving both bones and those involv- 
ing each separately, exposes to much repetition, and I have therefore 
followed the plan adopted in the other chapters and described them ac- 
cording to the position of the fracture of the tibia, as fractures of the 
upper end, of the shaft, and of the lower end, and have added a separate 
section for fractures of the fibula. The classification is not an ideal one, 
but its disadvantages appear to me to be less than those of others. 

A. Fractures of the Upper End of the Tibia and Fibula or of 
the Tibia alone. — The causes of these fractures are direct or indirect 
violence ; in the former a blow received directly upon the part, as the 

1 Diet, de Med. et Chir. pratiques, vol. xix. p. 496. 

2 Agnew's Surgery, vol. i. p. 981. 



UPPER END OF THE TIBIA AND FIBULA 



565 



Fia:. 331. 



fall of a heavy body or the kick of a horse ; in the latter a fall from a 
height or a twist of the limb. 

A man jumped from a height of two yards and fell with his leg bent 
under him, fracturing the tibia close to the knee. Velpeau saw a 
fracture caused in a man, 67 years old, by a fall to the ground while 
walking ; and in a case which came under my own observation, the tibia 
was broken just below the knee by a fall of another man from the 
track of the elevated railway upon the patient as he w r as walking in the 
street below. 

The line of fracture may be transverse, oblique, or vertical, in the 
latter case passing into the joint and perhaps separating only a portion 
of the articular end from the shaft, as in a case under the care of Follin 
in which the feet of the patient became entangled in the reins as he left 
a wagon and he was dragged by them for 
some distance ; the outer condyle of the tibia 
was broken off. Transverse fractures by 
direct violence, the fall of a stone, the kick 
of a horse, have been observed at four and 
seven centimetres from the articular edge. 
Comminuted fractures have been caused by 
direct violence and also (fig. 331) by falls 
upon the feet, the cylindrical portion of the 
shaft penetrating and splitting the head. 
Legouest observed such a result in a man 
who jumped from a second-story window, 
the head of the tibia into many 
Verneuil saw the epiphysis sep- 
arated in a child six years old whose leg 
had been caught between the spokes of a 
wheel ; the joint was not opened. One or 
two similar cases have been reported by 
others. 

In a case reported by Duplay and Marot, 1 a man 60 years old had 
his right leg broken by the fall upon it of a heavy stone. There was a 
marked angular displacement backward just below the knee which could 
not be reduced by traction but could be easily reduced by flexing the 
leg. It was due to the fact that the upper fragment w T as in the position 
of semi-flexion and remained so even when the lower part was extended. 
The region was immensely swollen, gangrene set in, and death took 
place on the thirteenth day. The autopsy showed a comminuted frac- 
ture of the upper end of the tibia extending into the joint and rupture 
of the popliteal vein. 

Ordinarily the displacement is not so marked as in this case, and it 
may take place in any direction, influenced therein by the direction and 
the character of the fracture and by the fracturing force. If the fibula 
remains unbroken and is not dislocated at its upper end it aids materi- 
ally in preventing any displacement that would involve shortening. To 



breaking 
fragments. 




Intra-articular fracture of the 
head of the tibia, with impaction 
and separation of the upper frag- 
ments. 



Progres Medical, April 29, 1876. 



566 FRACTURES OF THE BONES OF THE LEG. 

the other usual signs of fracture, abnormal mobility and crepitation, are 
added loss of function, deformity appreciable by the sight or touch, and 
a prompt and extreme swelling of the region. If the fracture extends 
into the knee-joint a later swelling corresponding in position to the syno- 
mial sac is superadded ; it may be merely a temporary effusion or the 
result of a suppurative arthritis which will seriously endanger the life 
and the limb of the patient. 

The proximity of the main vessels and nerves to the bones increases 
the chances of their being torn or pressed upon by the displaced frag- 
ments, as in the following illustrative cases. 

J. Bell. 1 Compound comminuted fracture of the tibia and fibula at the 
upper end. The leg was very much swollen, and some days afterwards 
it was recognized that the swelling was liquid. It was opened freely 
and a large quantity of blood-clot turned out, and then, as the bleeding 
continued from a deep artery, the limb was immediately amputated. 

Nepveu 2 reported a case under the care of Yerneuil. A man, 59 
years old, was run over by a wagon while intoxicated and suffered a 
compound fracture of the leg in its upper fourth, the wound being about 
8 centimetres long and the bone comminuted. Amputation was done 
through the lower third of the thigh, and the patient died four days after- 
wards. The anterior tibial artery was torn completely across, its upper 
end retracted into the popliteal space and its lower end to a point 6 
centimetres below the opening in the interosseous ligament through 
which the artery passes. The vessel, which was somewhat atheroma- 
tous, appeared to have been torn at this opening. 

Baudens. 3 A man was kicked by a horse and received a compound 
comminuted fracture of the leg in its upper third. The patient did well 
until about the twentieth day, when arterial hemorrhage took place. In 
searching for the w T ounded vessel a long sharp splinter was found im- 
bedded in the soft tissues near the posterior tibial artery and was re- 
moved. Three other hemorrhages folloAved, one immediately after the 
other, and then Baudens tied the femoral artery in its upper third. 

In the following case 4 the vessels appear to have been only compressed. 
A woman 37 years old was run over by a wagon and her left leg was 
broken in such a manner that the lower fragment was forced up into the 
hollow of the knee, leaving a marked depression just below the patella. 
The popliteal space was occupied by an enormous swelling which dis- 
tended the skin and caused severe pain. There was shortening to the 
extent of four or five inches which could not be overcome. Gangrene 
followed, and the limb was amputated on the nineteenth day. 

The prognosis of this injury is exceptionally serious, because of the 
proximity of the joint and the possibility of inflammatory complications 
and more or less complete loss of the functions of the knee which that 
involves, and also because of the exceptionally long period that is neces- 
sary to consolidation. The average period in seven cases collected by 

1 Principles of Surgery, vol. iv, p. 411. 

2 Bull, cle la Societe de Chirurgie, 1875, p. 369. 

3 Gazette des Hopitaux, 1855, p. 127. 

4 Bull, de l'Acad. Roy. de Med., 1845-46, p. 26. 



FRACTURES OF THE SHAFT. 



567 



Fig. 332. 




Arrest of growth fol- 
lowing injury to the 
upper epiphysis of the 
right tibia. (Bryant.) 



Poncet was about four months. No satisfactory ex- 
planation has been given of this peculiarity. 

Separation of the epiphysis may result in diminished 
growth of the leg, as in the case represented in figure 
332, in which the injury was received at the age of 
eight years and the shortening two years later 
amounted to an inch. If the fibula does not share in 
the injury in like manner its growth is unchecked and 
its superior length must be provided for either by 
bowing outward of its shaft or by dislocation of its 
upper end upward. 

Treatment. — Displacement, if present, must be re- 
duced by traction or bv extending or flexing the limb 
according to the character of the displacement, and 
retention erTected either by permanent extension or by 
confinement in a fracture box or upon a posterior 
splint. The indications vary so greatly in this re- 
spect with the position, direction, and extent of the 
fracture that rules of general application cannot be 
laid down. If the fibula is unbroken the displace- 
ment is usually slight and the retentive apparatus will 
be useful mainly to immobilize and prevent lateral displacement ; if the 
line of fracture runs obliquely into the joint, breaking off only a corner 
of the tibia, lateral displacement is the one to be guarded against lest a 
permanent genu valgum or varum should result ; if there is much com- 
minution of the upper fragment and the lines of fracture extend into the 
joint permanent extension will probably be necessary, together with 
lateral support of the fragments by pads or bandages. In any case 
particular attention must be given to prevent inflammation of the knee- 
joint, cooling lotions, the ice-bag, irrigation through a coil, according to 
the urgency of the conditions, and the immobilization should be absolute. 
After the lapse of a week or two, if the swelling has subsided and acute 
complications no longer threaten, a plaster bandage or plaster splint may 
be applied. 

If the fracture is compound and communicates with the joint, and if 
suppuration of the joint occurs, a free outlet for the pus must be provided 
at the earliest moment and the case must be treated with the strictest 
attention to antiseptic principles. It is better to drain the joint through 
special openings at its sides rather than through the wound which can 
hardly fail to be unsuitably j^laced for effective drainage. 



B. Fractures of the Shaft. — Fractures by direct violence may 
occur at any point ; those by indirect violence are much more frequent 
at or near the junction of the lower and middle thirds than at any other 
point. It seems probable, as taught more especially by Gosselin, that 
torsion of the limb is an important factor in the production of the frac- 
ture, the twist being due either to the forcible contraction of the muscles 
or to the propulsion of the upper portion while the lower one is fixed by 
the pressure of the foot upon the ground. 

The varieties of fracture common to other Ions: bones are found here, 



568 



FRACTURES OF THE BONES OF THE LEG 



and in addition a special variety, the V-shaped fracture, first pointed out 
by Gosselin, which although occasionally found elsewhere is much more 
frequent in the leg. In these, which are especially frequent below the 
middle of the bone, the upper fragment terminates in front and on the 
inner side in a more or less sharp triangular point, the lower fragment 
presents a similar point posteriorly, and from the bottom of the depression 
in the lower fragment which corresponds to the first point a fissure passes 
spirally downward and usually runs into the ankle-joint, 
Fig. 333. sometimes splitting off a superficial fragment on the pos- 

terior aspect as shown in figure 338. The extent of the 
fissures and the implication of the ankle-joint give this 
variety of fracture an especial importance. 

It is very rare for the tibia alone to be broken when 
the fracture is by indirect violence, for the force con- 
tinues to act, if only for a moment, and breaks the weaker 
fibula all the more easily, and usually at a higher point 
than the tibia. 

The subcutaneous position of the tibia throughout ibs 
entire length exposes its fractures greatly to the chance 
of becoming compound either by the direct action of the 
causative violence when the fracture is direct, or by the 
perforation of the skin by the end of one of the fras- 



■ 






$ 



ments, usually the upper one, when the fracture is in- 
direct. 

The displacements show the usual varieties, but the 
most common and important is the projection of the lower 
end of the upper fragment when it terminates in a point, 
as it usually does, upon the anterior and inner face of 
the bone. The contraction of the muscles draws the 
lower fragment upward, and this forces the end of the 
v-shaped fracture, upper one forward since the line of fracture is oblique 
from below upward and backward, and, in addition, the 
muscles of the calf tend to draw the heel backward and create an 
angular displacement which, of course, exaggerates the projection of the 
fragment. If the limb is raised and the knee kept partly flexed the 
tension of the quadriceps femoris acts in favor of the same displacement. 
In addition to the usual symptoms of crepitation, abnormal mobility, 
pain, and loss of function, there is also the irregularity in the outline of 
the subcutaneous portion of the tibia which may often be recognized by 
passing the finger along it. It is not always possible to say whether or not 
the fibula is broken as well as the tibia without making a more severe and 
painful examination than the need of the information will justify. When 
both bones are broken the mobility is usually much greater than when the 
tibia alone is broken, and by making gentle pressure with the finger along 
the line of the fibula the point of fracture can usually be determined. 

Beside the frequent complication of a communicating wound of the 
skin, and the comminution which is so often the result of direct violence, 
injury to the principal vessels is occasionally met with. Nepveu, 1 in a 



Bulletins de la Societe de Chirurgie, 1875, p. 365. 



FRACTURES OF THE SHAFT. 569 

very complete and elaborate paper read before the Surgical Society of 
Paris, collected more than fifty cases, among which are found examples of 
injury to both tibials, the peroneal, and the nutrient artery of the tibia. 
Injury to the tibial or peroneal nerves seems to be much more rare. The 
following cases are quoted in illustration. 

Case II. — Man 41 years old, oblique fracture with lacerated wound of 
the integuments, and rupture of the muscles caused by the passage of a 
heavy wagon. Spasms, trismus, opistothonos, and gangrene of the 
wound. Amputation on the thirteenth day, and death on the next. 
The autopsy showed that a splinter had penetrated the sheath of the 
anterior tibial artery and the substance of the peroneal nerve, there was 
an extensive neuritis, and a splintered fracture of the tibia. 

Case I. — Farabceuf presented to the Societe Anatomique (Bulletins, 
1866, p. 6) the specimens of a V-shaped fracture of the leg that termi- 
nated fatally on the seventh day. There was incomplete rupture of the 
posterior tibial artery, the vessel resting upon the point of the fragment. 
The inner and middle coats alone were torn. 

Case X. — A lad 16 years old was overthrown by a falling tree and 
received a comminuted fracture of the right tibia at its middle, an oblique 
fracture of the fibula, and a contused wound on the anterior surface of 
the tibia three inches above the ankle, with profuse hemorrhage from the 
anterior tibial artery which recurred when the provisional dressing was 
removed. The wound was enlarged, the splinters removed, and the 
artery tied. The patient made a slow recovery, after fever, profuse 
suppuration, and necrosis of part of the tibia. 

Case XXXIX. — A man 55 years old fell and broke both bones of the 
leg in the middle third, the upper fragment projected under the skin and 
there was a manifest tendency to return of the displacement after re- 
duction. About the fifteenth day he complained of pain in the calf, and 
a few days later a firm bluish swelling appeared at the middle of the leg. 
Amputation was done, and an aneurism of the peroneal artery found. 
The sharp fragments of the fibula had lacerated the vessel very irregu- 
larly. 

Case XLVI. — Man, overthrown by a wagon, simple fracture of both 
bones, removal of the dressings after the sixth week. Six weeks after- 
wards the patient noticed that a large tumor had formed at the outer 
part of the limb, beginning two or three finger-breadths above the ex- 
ternal malleolus, extending around the posterior part of the leg, and 
ending at the upper part of the inner aspect. It was fluctuating, did 
not pulsate, and its size was not modified by pressure above or below. 
At its lower and outer portion could be heard a single, rough, harsh 
murmur, and three finger-breadths above it in a circumscribed space 
corresponding to the point of fracture of the tibia were two distinct 
murmurs, the first stronger than the second. A fortnight later the tumor 
became very painful at its upper and inner part and was punctured. 
Hemorrhages followed and the limb was amputated. 

The autopsy showed a very oblique fracture of the tibia at the junc- 
tion of the middle and lower thirds. The hemorrhage came from nume- 
rous branches of the nutrient artery of the tibia opening on the surface 
of the fragment. 



570 FRACTURES OF THE BONES OF THE LEG. 

A simple fracture without persistent displacement will usually become 
firmly consolidated in six weeks ; but in the comminuted ones and in 
those that are oblique with persistent displacement the callus remains 
weak much longer. Complete recovery is long delayed by rigidity at 
the ankle, tenderness of the skin, feebleness of the circulation, and 
neuralgic pains which are more common after fractures of the leg than 
after those of other long bones. In the old and rheumatic this delay is 
especially prolonged. 

If the suppuration becomes free after a compound fracture it is pro- 
bable that complete recovery will' be postponed for even a much longer 
time, and that sinuses leading down to bare or necrosed bone will remain 
open for many months or will reopen at intervals. On the other hand, 
the subcutaneous position of the tibia makes it easier to drain the cavity 
of the fracture thoroughly and to remove splinters, and thus makes the 
danger to life less than after compound fracture of bones that are more 
deeply placed. 

Treatment. — Reduction of the displacement can generally be made by 
extension at the foot and counter-extension at the knee, this joint being 
slightly flexed to relax the muscles of the calf. In the more difficult 
cases in which spasm of the muscles opposes reduction, compression of 
the femoral artery for a few minutes, as suggested by Broca, has some- 
times proved useful in my experience. In a small proportion of cases 
complete reduction is impossible, probably because of the interposition 
of a muscular bundle between the fragments.. 

Maintenance of the reduction depends largely upon the character of 
the fracture ; when this is nearly transverse and toothed, the displace- 
ment is unlikely to recur ; but when it is oblique the difficulties of com- 
plete retention are extreme. The segment of the limb below the fracture 
is too short to permit extension through strips of adhesive plaster, as in 
fracture of the thigh, and the surgeon has to depend upon some form of 
lateral splints or an immovable dressing, neither of which will certainly 
prevent shortening, although the amount may be so slight as to be with- 
out practical importance. 

One of the simplest and most popular methods is the fracture box 
(fig. 33-1) with hinged foot-piece and sides. The foot-piece should be 

Fig. 334. 



Fracture box. 



movable so that it can be adjusted to the length of the limb, and the 
lower ends of the side-pieces should be perforated for the passage of a 
rod, against which the foot-piece can rest, and of cords by which it can 
be secured. When it is brought into use, the bottom of the box is first 
covered with a layer of oakum or cotton, the foot is suspended from the 



FRACTURES OF THE SHAFT. 571 

foot-piece by a broad piece of adhesive plaster extending from about the 
middle of the calf, under the heel, and along the sole, and tacked to the 
top of the foot-piece in such a way that the back of the heel does not 
rest upon the bottom of the box (I have sometimes used, in compound 
fractures, a long posterior plaster of Paris splint in place of this strip of 
adhesive plaster, in order to get additional solidity). The foot is then 
made fast to the foot-piece by a roller bandage, the turns of which pass 
across the dorsum of the foot, and behind the ankle and heel, and 
through vertical notches or slits in the foot-piece. Extension and 
counter-extension are then made at ' the foot and knee, the oakum 
adjusted under the limb to secure even support throughout its length, 
and the hinged sides of the box turned up and made fast by straps or 
bands tied about them. Oakum should be packed in between the limb 
and the sides of the box, and cushions or pads placed along its anterior 
aspect, and bound down by the straps which hold up the sides of the box. 
If the extended position of the knee is trying to the patient, the box 
may be swung from a cradle or a higher support, or Petit's fracture 
box (fig. 385) may be used. One of the advantages of having the knee 

Fi<?. 335. 




Petit's fracture box. 

flexed, is that this position opposes the occurrence of rotatory displace- 
ment, an accident which may easily escape notice when the limb is 
straight. The upper segment with the thigh rotates outward, while the 
foot remains fixed, and if the fragments unite in this position the 
patient will walk with the toes turned in. .If the surgeon is on the 
watch for this displacement it will hardly escape his notice, since the 
relative position of the patella and foot shows it very clearly. 

Wire troughs (fig. 336) are in general use in France as substitutes 
for fracture boxes, and afford equal facilities for inspection of the limb 
without moving or disturbing it. 

The general practice in the hospitals in New York is to place the 
limb in a fracture box for a few days, and apply lead and opium ; and 
then after the swelling has subsided to put on an immovable dressing of 
plaster of Paris, and let the patient get up. 



572 



FRACTURES OF THE BONES OF THE LEG. 



Plaster of Paris may be applied as a complete encasement (fig. 337), 
or in the form of the Bavarian splint (fig. 338), or as a posterior splint 



Fig. 336. 




Bonnet's gutter for the leg. 



(fig. 339) with or without one or two lateral ones. I am rather partial 
to the latter because they can be so made as to leave the region of the 



Fig. 337. 




Encasement of the leg in plaster of Paris. 



fracture open to inspection. The posterior splint should be thick and 
heavy, ten or twelve thicknesses of crinoline or cheese-cloth, and should 



Fig. 338. 




The Bavarian splint. 

reach from a little above the toes to the middle third of the thigh. The 
lateral splint should be of about the same length, and, starting from the 
outer side of the foot just in front of the ankle, should be wrapped 
around the dorsum, inner side, and sole, and then be carried up the 
outer side of the leg. The splints should be secured to the limb with a 
few turns of a roller bandage until after they have hardened, when 
strips of adhesive plaster may be substituted. These splints may be 
used while the case is still recent, and so may the Bavarian splint, but 



FRACTURES OF THE SHAFT. 



573 



Fig. 339. 



I think it is better to defer complete 
encasement in plaster until after the 
primary swelling has subsided. 

Many plans have been suggested by 
■which permanent extension may be 
made upon the limb to overcome short- 
ening in those cases in which this 
indication becomes a prominent one ; 
and in most of them the counter-exten- 
sion also is provided by the apparatus, 
and not by the weight of the body as 
in the treatment of fracture of the 
thigh. If a Volkmann's sliding foot- 
rest were used instead of a fracture 
box, or if the fracture box were placed 
upon a similar support, it would be suffi- 
cient to attach the weight to the box if 
it did not need to be very heavy or its 
use to be long continued. Otherwise 
the attachment must be by means of 
strips of adhesive plaster applied to the 
lower part of the leg in the usual 
manner. 

Figures 340 and 341 show Dr. Neill's 
apparatus, and figure 342 a somewhat similar one often used in the 
Massachusetts General Hospital when the fracture is in the middle third. 1 

Fig. 340. 




Posterior gypsum splint or gutter. 




Dr. Neill's dressing. 



Fig. 341. 




Dr. Neill's dressing. Compound fracture. 



The plaster strips for extension, in the latter, " reach from the top of the 
lower bandage to the spreader attached to the screw, and the counter- 



i The Medical News, April 8, 1882, p. 377. 



574 



FRACTURES OF THE BONES OF THE LEG 



extension from the lower edge of the upper "bandage to the top of the 
splints, where they are fastened." Pads are placed between the side- 
splints and the limb to prevent lateral displacement, and the whole 
bound together with straps. 



Fig. 342. 




Continuous extension in fracture of the leg. 

I have no experience with either method, but should doubt the effi- 
ciency of extension made by two sets of plaster strips with only a short 
interval between them. I should fear that the force of the traction would 
be exhausted upon the intermediate strip of skin, and that the fragments 
would be left free to override to as great an extent as under other 
dressings. ' 

Lateral splints made of binders' board, or other material that can be 
moulded to the leg and foot, are sometimes used, especially when the 
fracture is in the lower third. They should be well padded and open- 
ings should be made at the points corresponding to the malleoli. 

The bivalve cushion (page 161) is highly recommended for use in 
simple cases or in emergencies. 

In Liston's splint (fig. 343) the counter-extension is provided by a 
thigh-piece adjustable at any desired angle to the leg-piece ; the foot- 



Fig. 343. 




Liston's double inclined plane. 

piece also can be adjusted according to the length of the leg. The 
splint is suitably padded or lined, the foot made fast to the foot piece by 
bandaging, and then the thigh to the upper part in like manner, while 
extension is made with the hands. It is not probable that this splint 
will protect against overriding if there is any marked tendency thereto. 

Figure 344 shows a similar splint with Salter's suspending apparatus. 

Malgaigne's point (figs. 345 and 346) was designed for use in cases 
in which the tendency of the lower end of the upper fragment to dis- 
placement forward could not be controlled by splints. It consists of a 
curved metal band fastened over the limb by a strap that passes behind 



FRACTURES OF THE SHAFT. 



575 



the posterior splint. It is placed a little above the fracture, and the 
central pin, which has a sharp point, is screwed down through the skin 



Fis:. 344. 




Mclntyre's splint and Salter's swim 



and made to press directly upon the upper fragment and hold it in place. 
Most surgeons, and probably all patients, would hesitate to use this 




Malgaigne's point. 

Fig. 346. 




Malgaigne's point applied. 

means, and in a few cases its use has caused much pain, and in others 
erysipelas. In a thesis by Rioms, 1 36 cases treated in this manner are 

1 Diet, de Med. et Chir. prat., vol. xix. p. 521. 



576 



FRACTURES OF THE BONES OF THE LEG. 



reported, 10 of which were compound fractures. The instrument main- 
tained the reduction in every case, and apparently it was not used in 
any of them until after other means had proved ineffectual. 

Anger's apparatus (fig. 347) seeks to accomplish the same result by 
pressure and to avoid injury to the skin by shifting the points of pres- 
sure as often as may be necessary. 



Fig. 347. 




Anger's apparatus for alternate pressure. 



Division of the tendo Achillis has been resorted to in some cases. 
When the fracture is compound, the limb may be placed upon a pos- 
terior splint (fig. 348) or suspended, as in fig. 349, the anterior splint 

Fig. 348. 




Compound fracture. Lister dressing and plaster splint. 

being placed outside the dressings of the wound. If the wound suppu- 
rates and the pus burrows it will probably become necessary to use the 
interrupted or bracketed plaster splints (fig. 350) so as to obtain the 
necessary space for the dressing and counter-openings. 

C. Fractures at the Lower End of the Leg. — In this group I 
place some exceptional fractures of both bones, in which the lower end 
of the tibia is crushed or splintered, caused by a fall from a height upon 
the feet, and the numerous fractures of one or both bones at or near the 
joint, "malleolar fracture," caused by forcible inversion or eversion of 
the foot, fractures which present several anatomical varieties, of which 
the more common is known as Pott's fracture. 



FRACTURES AT THE LOWER END OF THE LEG. 577 
Fig. 349. 




Anterior and posterior plaster splints. A is a wire bent into loops for the purpose of suspension. 

Fig. 350. 




Interrupted plaster dressing. A, the straight posterior iron splint. 

There is but little to be said concerning the first, and I shall merely 
quote briefly the descriptions of a few reported cases. One was re- 
ported by Ohassaignac and Richelot, the translators into French of Sir 
Astley Cooper's Fractures and Dislocations. The foot was displaced 
inward and seemed to be shortened ; the fibula was broken and its mal- 
leolus displaced backward ; redaction was impossible. At the autopsy 
a fragment comprising the posterior half of the articular surface of the 
tibia was found broken off and displaced backward about an inch, but 
still resting on the astragalus. Tne ligaments were intact. 

In another case also reported by Chassaignac, in 1858, the fracture 
was caused by a fall from the third floor ; the limb was amputated two 
months afterwards. The tibia was broken four finger-breadths above 
the joint and the lower portion was split into four secondary fragments 
by the penetration into it of the upper one. The fibula was the seat of 
a double fracture also in the lower third ; the intermediate piece was 
fuur centimetres long, necrosed, and imbedded in the callus. 
37 



578 



FRACTURES OF THE BOXES OF THE LEG. 




A third is a specimen in the museum at Val-de-Grace described by 
Poncet. 1 Figure 851 shows the direction of the lines of fracture, the 
lower end of the tibia having been broken into six 
Fig. 351. fragments. 

Similar cases are described by Cooper and Mal- 
gaigne. 

No rules of treatment can be formulated in 
advance ; each case must be treated in accordance 
with its special indications. If the attempt is 
made to preserve the limb, especial attention 
should be paid to the position of the foot in the 
splints in order that, if ankylosis of the ankle-joint 
follows, the sole may rest squarely on the ground 
in walking. Even a slight deviation, either to one 
side or from a right angle in the antero-posterior 
plane, is a source of much inconvenience. 

The fractures of the malleoli and of the tibia 
and fibula just above the ankle that are produced 
by forcible inversion or eversion of the foot with 
rotation of the toes to the inner or outer side pre- 
sent several varieties which differ widely in the 
extent and position of the lines of fracture, but 
which can be grouped advantageously according to 
their supposed mode of production. The mechan- 
ism of these fractures has been discussed for more 
than a century and many explanations and theories concerning it have 
been suggested the discussion of which here would not be profitable, and 
I shall follow the etiological classification and describe : 1st fractures 
by inversion and adduction of the foot, and 2d fractures by eversion and 
abduction of the foot. The very complete experimental and clinical 
study of the subject made by Tillaux 2 shows that all these fractures can 
be produced in these ways, and the classification is not only simple and 
justified by experiment but it also corresponds with important clinical 
differences. 

Figure 852 may serve to recall some of the anatomical peculiarities 
of the ankle-joint which are principally concerned in the production of 
these fractures, such as the strong lateral ligaments 
upon the malleoli, the inferior interosseous ligament 
and fibula together, and the astragalus set in between 
a mortise. The only motion which this joint permits normally is in the 
direction of flexion and extension, except that when the foot is extended 
(plantar flexion) a slight degree of rotation about a vertical axis is pos- 
sible, an exception which does not affect the correctness of the statement 
that the existence of lateral mobility in the joint is a proof that it has 
been injured or diseased. 

1. Fractures by Inversion and Adduction of the Foot. — In this movement 
the foot turns so that if the individual is upright its outer border rests upon 



Comminuted fracture of 
the lower portion of the 

leg. 



and their insertions 
binding the tibia 
:he malleoli as in 



1 Diet, de Med. et Chir. prat., vol. xix. p. 531. 

2 Bull, de l'Academie de Medecine, 1872, pp. 339 and 819, and Anatomie topogra- 
phique, p. 1172. 



FRACTURES OF THE LOWER END OF THE LEG. 



579 



the ground, the sole is directed inward 
(" tibial-fiexion"),and the toes are also 
turned inward. The external lateral 
ligaments are put upon the stretch and 
if they resist the strain, if a simple 
sprain is not produced, the fibula breaks 
either above or below the lower tibio- 
fibular articulation. 1 If it breaks below, 
if the fracture is of the malleolus, it 
may be at its apex or, more commonly 
according to Tillaux, at its base ; the 
line of fracture is transverse and the pe- 
riosteum untorn, there is no displacement 
of the fragment or of the foot, and the 
only sign of fracture is the localized pain 
or pressure at its seat. The inner side 
of the ankle is uninjured. If, however, 
the action is continued its force is trans- 
mitted through the astragalus to the in- 
ternal malleolus, the tip of which may 
then be broken off by the direct pressure 
upon it. Tillaux produced this second- 
ary fracture several times experiment- 
ally, and thinks he has seen it upon the 
living, the evidence being the existence 
of a fixed pain at the base of the in- 
ternal malleolus and sometimes a slight groove recognizable by the finger 
at a point corresponding to the seat of the pain. 

Sir Astley Cooper 2 describes under the title of " dislocation of the 
tibia outwards" an oblique fracture of the internal malleolus (fig. 35-^), 
and speaks of it as the most dangerous of the three disloca- 
tions because produced by greater violence and attended with 
more injury to the soft parts and bones than either of the 
others. The malleolus alone may be broken off or a part 
of the articular surface may remain attached to it ; the 
astragalus is sometimes fractured and the lower portion of 
the fibula broken into several splinters, or the external lat- 
eral ligament ruptured. The lesions, as described by him 
in this case, may be considered an exaggeration of those of the 
preceding paragraph, due to greater violence and to lareral 
bodily displacement of the foot, rather than to its inversion. 

The fibula may break above the point where it rests 
against the tibia, that is, the tip of its malleolus is drawn 
inward by the forced movement of the foot, and the shaft of 
the bone is correspondingly sprung or tilted outward. The 
usual seat of the fracture in this case is one and a half 
inches above the tip of the malleolus. This fracture must Fracture °j 
not be confounded with the common one, to be subsequently malleolus. 




Vertical section through the malleoli. 



Fisr. 353. 




* For a possible alternative see Fractures of the Calcaneum, p. 
2 Loc.cit., p. 230. 



590. 



580 



FRACTURES OF THE BONES OF THE LEG. 



Fig. 354. 



described, in which the foot is twisted outward, the internal lateral liga- 
ment torn or the internal malleolus broken, and the fibula broken at a 
point somewhat higher up, about two and a half inches above its tip. In 
the fracture by inversion the symptoms are very different, for the region 
of the internal malleolus and deltoid ligament is entirely free of pain 
(except in the rare contingency of fracture of the internal malleolus by 
pressure from within the joint outward), the foot is not displaced out- 
ward, and there is very little, if any, lateral mobility in the joint. The 
following case will illustrate the fracture, which is not a common one. 

K., 49 years old, was admitted to Bellevue Hospital February, 1882. 
He said that while quarreling with a man he twisted his foot inward, felt 
pain at the ankle, and found himself disabled. There was no displace- 
ment of the foot, and no tenderness and no ecchymosis on the inner side 
of the ankle. There was localized pain on pressure and distinct crepi- 
tus 1 J inches above the tip of the external malleolus, and by pressing 
the latter in toward the foot with one finger the upper end of the lower 
fragment could be felt to tilt outward ; by alternate pressure on its ends 

the fragment could be rocked upon the 
tibia. The line of fracture was oblique 
from above downward and inward. 

If the force continues to act after the 
fibula has broken above the inferior 
interosseous ligament, the tibia may break 
transversely just above its lower articu- 
lar surface. Tillaux speaks of this as a 
fiacture that had not been described 
before, but it seems to be the same as 
some described by Malgaigne as " supra- 
malleolar fractures," and of which he gives 
fig. 354 as an example. Tillaux produced 
this fracture several times experimentally, 
and claims to have recognized it also upon 
the living ; I remember to have seen a case 
in his wards in 1874 in which he made this 
diagnosis, basing it on the existence of a 
limited line of pain on pressure crossing 
the internal malleolus two centimetres 
above its point and continuing along the 
front of the tibia just above its articular edge, on a painful point six 
centimetres above the tip of the external malleolus, absence of deformity, 
and slight mobility of the foot from behind forward with loud crepitus. 

He reports 1 a case which he considers a most striking confirmation of 
his theory of the mechanism of this fracture by inversion, one in which 
dislocation of the upper end of the fibula took the place of fracture of 
this bone. A man 38 years old had fallen with his leg caught under 
him. Tillaux recognized a transverse fracture of the tibia three finger- 
breadths above the tip of the malleolus and a diastasis of the upper end 
of the fibula. There was but little displacement at the fracture, the 




Supra-malleolar fracture with crushing, 
(Malgaigne.) 



1 Anatomie topograpliique, p. 1174. 



FRACTURES OF THE LOWER EXD OF THE LEG. 581 

lower fragment had slipped forward, and the extensor tendons were 
slightly raised and stretched. The upper end of the fibula moved very 
freely on pressure and gave a loud cartilaginous crepitus. 

The diagnosis is made by attention to the symptoms already mentioned ; 
the principal ones, in fracture at or just above the base of the malleolus, 
are the abnormal mobility of the fragment recognized by pressure with 
the end of the finger, the localized pain, and the absence of displacement 
of the foot and of symptoms on the inner side of the ankle except when 
the tip of the internal malleolus is also cracked. 

The prognosis is relatively favorable because of the absence of dis- 
placement, the limited extent of the injury, and, in some cases, the non- 
implication of the joint. In the variety last described, that in which the 
fracture crosses the tibia, the prognosis may be made more grave by the 
splitting of the articular fragment. 

The treatment consists in simple immobilization in a good position in 
cases in w r hich the fracture is limited to the fibula or to the fibula and inter- 
nal malleolus, preferably by a plaster splint or dressing. I have treated 
one or two cases by simple rest in bed, with cooling lotions or pressure 
to reduce swelling, and the result has been satisfactory. In the supra- 
malleolar variety displacement must be corrected if present and its recur- 
rence guarded against. 

2. Fractures by Fversion and Abduction of the Foot. — In this move- 
ment the foot turns toward the outer side (fibular flexion), and at the 
same time the toes are turned outward. The internal lateral ligament is 
put upon the stretch and either it is torn off the malleolus or calcaneum, 
or the malleolus is broken transversely at its base by avulsion. The 
force continuing, the astragalus is pressed against the external malleolus 
and either forces it directly outward with rupture of the inferior interos- 
seous ligament and diastasis of the lower tibio-fibular articulation, or by 
forcing it outward produces first a compensatory curving inward of the 
shaft of the fibula followed by its fracture at about 2 J inches above the 
tip of the malleolus and then by the rupture of the inferior interosseous 
ligament or the tearing off of the portion of the tibia to which this liga- 
ment is attached. In a typical and complete case there are three frag- 
ments : the internal malleolus, the external malleolus and adjoining por- 
tion of the shaft of the fibula, and the lower outer articular border or corner 
of the tibia as shown diagrammatically in figure 355. This is the common 
Pott's fracture, the capital feature of which, with reference to the prog- 
nosis, is the separation of the tibia and fibula, the widening of the mortise 
in which the astragalus lies. It is more common, I think, for the internal 
malleolus to break than for the internal lateral ligament to tear, and 
Tillaux says that in his experiments he always found that the inferior 
interosseous ligament had resisted and had torn off the portion of the 
tibia to which it was attached. 

In extreme cases the broken end of the tibia may be forced through 
the skin, making the fracture a compound one and opening the joint, or 
the astragalus may be forced up between the tibia and fibula. 

The symptoms are the displacement of the foot to the outer side (fig. 
356) with consequent prominence of the internal malleolus, eversion 
of the sole of the foot usually, sometimes a depression, "axe-cut," on 



582 



FRACTURES OF THE BONES OF THE LEG. 



the outer side of the leg at the point where the fibula is broken. Exten- 
sive ecchymoses below the ankle on both sides, pain or pressure at or 
below the internal malleolus and over the fibula at a point two or three 
inches above the tip of the external malleolus, lateral mobility in the 
ankle-joint. 



Fig. 355. 



Fisr. 356. 





The usual three lines of fracture iu Pott's 
fracture at the ankle 



Displacement in Pott's fractun 



The prognosis in simple fractures without displacement or in those in 
which reduction can be made and maintained is good, that is it may be 
expected that consolidation will take place in from four to six weeks, 
that the stiffness will gradually disappear, and that the joint will recover 
its functions in great part or entirely. But if the displacement is not 
thoroughly reduced the stability of the joint is lost, the foot lies outside 
the axis of the leg, and the weight of the body tends to evert it and to 
strain the internal lateral ligament. The disability is then great. An 
extreme degree of this deformity is shown in figures 357 and 358. 

If the fracture is compound the prognosis is much more grave, and it 
is not uncommon to see the case end in ankylosis or amputation. 

The treatment consists in the complete reduction of t}ie displacement 
and the maintenance of the foot in such a position that the displacement 
cannot recur in even the slightest degree. The success of the treatment 
depends upon the thoroughness with which this indication is met. It is 
not sufficient to bring the foot back to the axis of the limb, it must be 
inverted and held so. It is essential that the malleoli shall again em- 
brace the astragalus snugly and that the internal lateral ligament shall 
not be lengthened if it has been torn, or that the internal malleolus shall 
fail of close union if it has been broken. 

If there is much swelling, ecchymosis, and tenderness, if blebs have 
formed, I prefer to postpone the application of a permanent dressing for 
a week or ten days, keeping the limb meanwhile in a fracture box, 
or upon a posterior plaster splint in good position, that is, with the 
sole inverted and the heel well supported, and applying lead and 
opium constantly. After the swelling has subsided I apply a plaster of 
Paris bandage from the toes nearly to the knee and make it especially 



FRACTURES OF THE LOWER END OF THE LEG. 



583 



thick at the ankle. In addition to the usual circular turns I pass the 

bandage several times like a stirrup from one side of the leg under the 

instep to the other side to aid in keeping the foot inverted until the 
plaster has hardened, and secure them with other circular turns. 



Fi£. 357. 



Fig. 358. 





Vicious union after fracture of the fibula. 



Vicious union after fracture of the fibula %y 2 
inches above the tip of the malleolus. 



During the application of the bandage the foot must be kept strongly 
pressed to the inner side by one hand pressed against the outer side of 
the heel and instep below the malleolus, and the other making counter- 
pressure on the inner side of the tibia just above the ankle. The pres- 
sure on the foot must be made behind the medio-tarsal joint; pressure 
on the front part of the foot may deceive by simply rotating the toes 
inward while the tarsus remains displaced to the outer side or everted. 

If, for any-reason, I wish to keep the ankle exposed to view, as in 
cases in which the tendency to displacement is marked, I use posterior 
and lateral plaster splints made usually of eight or ten thicknesses of 
crinoline soaked in plaster cream. The posterior splint extends from 
the toes to the knee, and the lateral one is either single and extends 
from the dorsum of the foot around the sole and up the inner side of the 
leg, or it is double and passes under the sole like a stirrup. A few 
turns of a roller bandage will hold them in place until they harden. 
Such a bandage will usually immobilize the limb effectually. 

A dressing which has been much used in the past, but which has now 



584 



FRACTURES OF THE BONES OF THE LEG 



given place to the immovable dressings is Dupuytren's splint (fig. 359). 
It may be found useful during the first week or ten days before the appli- 
cation of the permanent dressing. It consists of a straight wooden 
lateral splint somewhat longer than the leg, and four or five inches wide, 



Fiff. 359. 




Dupuytren's splint. 

and a long thick pad. The splint is placed on the inner side of the leg, 
with the pad between and ending just above the ankle, and is secured 
below the knee with a few turns of a roller bandage. The foot is then 
pressed inward and secured by a bandage, the turns of which pass under 
and behind the heel and across the dorsum of the foot and the outer side 
of the ankle not higher than the base of the malleolus. It must be re- 
membered that the object is to press the foot forward and inward, and 
to invert its sole, and to press the external malleolus against the tibia. 

It is very easy to be deceived with regard to the relative positions of 
the astragalus, tibia, and external malleolus after this accident, espe-. 
cially if the surgeon looks only at the front part of the foot. I quote 
the following case as an example of this deception, of the extreme dis- 
placement that may follow fracture even by slight violence, and of the 
occasional difficulty of reduction. It was reported by Polaillon. 1 

A woman 58 years old, was admitted to La Pitie,Feb. 11, 1880 ; the 
previous evening while drawing off her boot with her hands she had 
" turned" her foot outward. There was found a fracture of the fibula two 
finger-breadths above tiie malleolus, very marked prominence of the inter- 
nal malleolus, and dislocation of the foot to the outer side. Chloroform 
was given and reduction attempted, but without success, and then the limb 
was placed on Dupuytren's splint with the hope of making reduction 
progressively. Ten days afterwards the dressing was removed because 
of the pain, and because the skin covering the internal malleolus had 
become gangrenous ; " at this time the foot showed no longer any ten- 
dency to be displaced outward, and it seemed as if the reduction had 
made notable progress." 

The slouirh fell, the wound w T as dressed antiseptically, but the patient 
died of erysipelas four months after the accident. 

The specimen shows an oblique fracture of the fibula beginning five 
centimetres above the tip of the malleolus, passing downward and for- 
ward, and terminating two centimetres above it. The malleolus had 
preserved its relations with the outer side of the astragalus and was 
displaced outward so far that the astragalus had entirely left the articu- 
lar surface of the tibia, and lay on its outer side in contact with the 
upper fragment of the fibula. 

1 Bull, de la Societe de Chirurgie, 1880, p. 436. 



FRACTURES OF THE LOWER END OF THE LEG. 585 

In his comments on the case he says, " the improvement which I 
obtained in the form of the limb by Dupuytren's dressing, was due to a 
sort of turn of the foot inward. It was such that the foot seemed to 
have been brought back into the axis of the leg, and I had no doubt but 
that the patient would be able to walk very well when cured. But the 
specimen shows that this reduction was only apparent." 

The following case is interesting because of the success of the attempt 
to correct deformity due to union in a faulty position. It was reported 
by Le Dentu. 1 

A man 55 years old, broke his right leg, Dec. 7, 18T9. When first 
seen by Le Dentu, March, 1880, there was a sharp angular displace- 
ment eight centimetres above the external malleolus ; the foot, deviating 
sharply to the outer side, made an angle of about 45° with the leg. 
The internal malleolus was displaced with the foot, the lower end of the 
tibia was very prominent above it, and the skin at that point was ad- 
herent to the bone and livid, and threatened to ulcerate. 

The patient was chloroformed March 22d, and the bones retractured 
with a modified Collin's osteoclast, an instrument composed of a bar 
carrying three adjustable arms, of which the upper one rested against 
the outer side of the le«\ the middle one against the inner side iust 
above the malleolus, and the third against the outer surface of the foot 
and ankle. The middle one faced outward and was used to make the 
pressure, the other two faced in the opposite direction, and furnished 
the support or counter-pressure. The refracture was effected easily, 
and the displacement entirely corrected ; the limb was placed in a solid 
plaster splint, and kept there for six weeks. There still remained a 
slight deviation outward, but the result was satisfactory, the sole of the 
foot rested squarely on the ground, and the patient, at the time of the 
report, three months after the operation, could use the limb. 

Dr. Fenger, 2 of Chicago, has got good results in cases in which con- 
solidation had taken place with outward deviation of the foot by "supra- 
malleolar osteotomy." He exposed the tibia two inches above the internal 
malleolus, and removed a wedge-shaped piece the base of which, one 
inch in breadth, was on the inner surface of the bone, the apex at the 
outer surface ; the foot could then be brought back into the line of the Ions; 
axis of the leg after fracturing the fibula. In his second case he per- 
forated the fibula several times with a drill to facilitate its fracture. 
The results of his operations appear to have been satisfactory, although 
full details of the condition of the joint are not given. 

I saw a similar operation done by Dr. Thos. T. Sabine, at St. Luke's 
Hospital, [New York, in January, 1881, to relieve the same disability. 
He divided each bone about an inch above the base of the malleolus with 
a chisel through separate incisions, and was then able to bring the foot 
into the axis of the leg without removing a wedge of bone. The opera- 
tion was done antiseptically, and the patient made a good recovery. 

This operation meets only one indication, it brings the foot back into 
line but it does not correct the separation of the malleoli, and it changes 

1 Bull, de la Societe de Chirurgie, 1880, p. 419. 

2 Medical News, April 15, 1882, p. 398. 



586 FRACTURES OF THE BONES OF THE LEG. 

the direction of the articular surface of the tibia so that it faces inward 
instead of being horizontal. 

Excision of the ankle, partial or complete, to overcome the disability 
due to consolidation of the fracture in a faulty position, is clone quite 
frequently by the French surgeons. The details of the operation vary 
according to circumstances, but in all the entire articular surface of the 
tibia and usually the upper articular surface of the astragalus are re- 
moved. Verneuil removes the external malleolus also, and resects the 
tendons of the peroneal muscles and tibialis posticus, to prevent eversion 
of the foot. Polaillon and Terrillon leave the external malleolus in place 
as a support during repair, but break the shaft of the fibula with a chisel 
at the seat of the original fracture as a first step in the operation. This 
makes it easy to turn out and excise the lower end of the tibia through 
a vertical incision on the inner side. Ankylosis is sought for, and the 
result appears to be satisfactory. 1 

D. Fractures of the Fibula. — In this section are included only the 
less common fractures, those occurring above the lower third, and not 
due to forcible twisting of the foot. The fracture which occurs so fre- 
quently in the lower third in connection with rupture of the internal 
lateral ligament or fracture of the internal malleolus has been described 
in the preceding section. 

Fractures of the upper end of the fibula may be produced by direct 
violence, by muscular action (contraction of the biceps), or by violent 
bending of the leg to the inner side by which the external lateral liga- 
ment is put upon the stretch and the head of the fibula, to which it is 
attached, torn off". The reported cases are not very numerous. 

In April, 1882, a child, about two years old, was run over by a street 
car and brought to the Presbyterian Hospital. In addition to other in- 
juries which were promptly fatal, there was a lacerated wound on the 
outer side of the right leg exposing the upper end of the fibula and 
opening the knee-joint. The epiphysis of the fibula was completely de- 
tached from the shaft and from the tibia and remained attached to the 
external lateral ligament and the tendon of the biceps ; there was also an 
incomplete fracture of the shaft of the fibula three-fourths of an inch 
below the epiphyseal line, and the intermediate portion was denuded of 
its periosteum which remained attached to the epiphysis. I showed the 
specimen to the N. Y. Surgical Society April, 18s2. 

Gurlt 2 quotes three cases in which the head of the fibula was broken 
off by the forcible contraction of the biceps ; one of them is quoted in 
Chapter IV., p. 96. 

Dupla;y 3 reported two cases in which the fracture was caused by vio- 
lent bending of the leg to the inner side. The patients were men, the 
one 48 and the other 60 years old, who were caught in machinery and 
whirled around, their bodies and limbs striking against a neighboring 
wall. At the upper end of the fibula could be felt a bony tumor as large 

1 Bull, de la Societe de Chiru-rgie, 1882, pp. 61, 65, 71, 87, 430. 

2 Lehre der Knochenbriichen, vol. i. p. 243. 

3 Bull, de la Societe de Chirurgie, 1880, p. 218. 



FRACTURES OF THE FIBULA. 587 

as a large hazel-nut, very movable laterally, rising when the leg was 
flexed, and descending when it was extended. It was directly continuous 
with the tendon of the biceps, and below it was a deep depression that 
would admit the thumb. There was free lateral mobility at the knee, 
and the tibia could be dislocated inward. Numerous contusions on the 
outer side of the leg and foot showed where the violence had been re- 
ceived, and one of the patients was able to describe how the leg had been 
bent inward. 

Paralysis of the muscles and loss of sensation in the region supplied by 
the peroneal nerve were noticed in one of the patients a few days after 
the accident, and persisted ; when he left the hospital, five months after- 
wards, the limb was useless, and the fracture had not united. 

The other patient died. The autopsy showed that the fracture passed 
below the upper tibio-fibular articulation, which, however, was opened. 

In the discussion that followed Perrin reported a similar case ; the 
patient's leg was caught between the ground and the body of the horse 
he was riding, and the head of the fibula was torn off. There was also 
a diastasis of the knee, and paralysis of the muscles supplied by the 
peroneal nerve. Two months afterwards the paralysis still existed. 

The wide separation of the fragments by the retraction of the biceps 
makes bony union improbable, but it does not appear in Gurlt's cases 
that any disability ensued. In Duplay's case the disability was the 
consequence of the paralysis. 

The treatment should be immobilization of the limb, and, in case of 
associated sprain or dislocation of the knee, measures to control or pre- 
vent inflammation of the joint. Immobilization with the knee fully flexed 
would favor close bony union of the fracture by relaxing the biceps, and 
possibly the position could be borne for a sufficient length of time. 

Fractures of the shaft are produced by direct violence. The displace- 
ment is slight because of the support given by the tibia, and the diagnosis 
is made upon the localized pain and the crepitus. In a case reported 
by Terrier 1 the bone was broken three finger-breadths below its upper 
end in a fall down a staircase, apparently by direct violence. There 
was no displacement. Symptoms of inflammation of the peroneal nerve 
appeared promptly, numbness and anaesthesia of the dorsum of the 
foot, painful spasms of the peroneal and extensor muscles, paroxysmal 
attacks of acute burning pain in the insensitive regions occurring spon- 
taneously or on the slightest touch, and paresis of the corresponding 
muscles. Improvement began after a month, and the fracture consoli- 
dated, but when last seen, nearly a year later, the patient still com- 
plained of the paroxysmal pain, and the foot was cedematous. 

The only treatment needed by the fracture is immobilization of the 
foot and ankle, preferably in a plaster or silicate bandage extending from 
the toes to the knee. The dressing may be removed in four or five 
weeks, but crutches should be used for a fortnight longer. 

1 Bull, de la Societe de Chirurgie, 1880, p. 222. 



588 FRACTURES OF THE BONES OF THE FOOT. 



CHAPTER XXVIII. 

FRACTURES OF THE BONES OF THE FOOT. 

With very few exceptions these fractures are produced by direct vio- 
lence or by falls upon the feet from a height. According to the table in 
Chapter I. they constitute about three per cent, of all fractures. Of 172 
cases in Agnew's tables 77 were compound or compound comminuted 
fractures. 

A. Fractures of the Astragalus. — These are commonly the result 
of falls from a height, the bone being crushed between the calcaneum 
and the tibia, and the lesion being frequently associated with fracture of 
the calcaneum and with dislocation at the ankle and fracture of the fib- 
ula. In 9 of 10 cases collected by Monahan 1 the cause was a fall upon 
the foot; in 9 there was also dislocation at the ankle or fracture of the 
fibula, and in 8 the injury was compound. 

The direction and extent of the line of fracture vary greatly ; the 
bone may be divided transversely into anterior and posterior halves, or 
longitudinally, or horizontally, or into several pieces, and the fragments 
may be widely separated and displaced. 

When there is no displacement or external w x ound the diagnosis may 
be very difficult, because the symptoms are not distinctive, and indicate 
only severe injury to the foot, pain, swelling, inability to bear the weight 
of the body on it, and perhaps crepitus on handling or flexing and ex- 
tending it. Mr. Bryant 2 thinks fracture without displacement is more 
common than is generally supposed, and refers to two cases in which he 
" removed from boys who had acute inflammation of the bone and joint, 
following injury, the whole of the necrosed upper articular surface 
with half the thickness of the astragalus, and in both good results fol- 
lowed." In another case he removed the upper half of the astragalus 
that had been fractured six months previously and displaced so as to 
present its upper articular facet inward. 

When there is no displacement the treatment is directed simply to im- 
mobolize the joint and control the inflammation ; after the swelling has 
subsided the plaster bandage should be applied, especial attention being 
given to the position of the foot which should be at right angles to the 
leg in the antero-posterior plane and without the slightest inversion or 
eversion of the sole. This is a capital point in the treatment of all in- 
juries to, or after operations upon, the ankle which may result in anky- 
losis. 

It is an open question whether a displaced fragment in a case of sim 

1 Quoted by Hamilton, loc. cit., p. 562. 2 Surgery, p. 858. 



FRACTURE OF THE CALCANEUM. 589 

pie fracture should be removed by incision or should be replaced. The 
reported cases are too few and the circumstances too various to allow a 
rule of treatment to be formulated. It seems probable that the displaced 
fragment will die and provoke suppuration, especially if there is much 
shattering of the bone or rupture of the capsule and ligaments through 
■which the blood supply comes. Those who have confidence in the anti- 
septic method would probably not hesitate to remove the fragment, per- 
haps also the remainder of the bone, immediately ; those whose confi- 
dence has been shaken by reverses would prefer to wait until nature has 
shown the limits of her power to repair the damage, unless the displace- 
ment was extreme, could not be corrected, and threatened to cause ul- 
ceration of the skin. Under such circumstances I should think imme- 
diate removal was fully justified. 

In compound fractures the fragments should be removed, and probably 
it is best that all the bone should be removed if the attempt is made to 
save the member. The principles laid down by Langenbeck 1 for the 
treatment of gunshot injuries of the ankle will serve as a guide. He 
urges the early application of the plaster bandage and free incisions for 
the relief of tension and evacuation of the discharges ; fever and pain 
being more certain indications for the latter than swelling and fluctuation 
without them. In injury of the astragalus the incision should be made 
between the extensor tendons of the first and second toes ; splinters can 
be easily removed through it and, if necessary, it can be prolonged to 
the scaphoid and all of the astragalus removed. 

After excision ankylosis should be sought for. 

In gunshot fracture of both malleoli and the astragalus with extensive 
splintering he makes total excision, but if either malleolus is only broken 
and not splintered he leaves it. 

The fundamental principle is to secure thorough drainage, and if the 
removal of one malleolus and the upper articular surface of the astragalus 
is necessary for this purpose it should be done. 

For the removal of the whole of the astragalus he recommends a "f- 
incision on the inner side, the centre of the horizontal branch lying two 
finger-breadths below the tip of the malleolus. This gives easy access 
to the inner and inferior surfaces of the bone and facilitates the division 
of the internal lateral and the interosseous ligaments. 

B. Fracture of the Calcaxeum. — -This bone may be broken by a 
fall upon the foot from a height, by contraction of the muscles attached 
to the tendo Achillis, and by foicible inversion of the sole of the foot. 
The extent and position of the fracture vary with the causes. 

In a fall directly upon the sole the bone is splintered or crushed, and 
especially so in its anterior half, and its vertical diameter is diminished 
by the crushing and its transverse diameter increased (fig. 330). Some- 
times the bone is also split longitudinally. 

There is some reason to think that forcible pressure upon the ball of 
the foot, dorsal flexion, resisted by the contraction of the muscles of the 
calf, may produce the same result by the following mechanism: the arch 

1 Archiv fur Klin. Cliirurgie, vol. xvi., 1874, p. 479. 



590 FRACTURES OF THE BOXES OF THE FOOT. 

of the foot is extended, the thick, strong inferior calcaneo-scaphoid liga- 
ment made tense, and the calcaneum broken behind the insertion of this 
ligament; then, the force continuing to act, the broken bone is further 
crushed by the astragalus. 

Fig. 360. 




Fracture of the calcaneum, with crushing. 

Gascoyne 1 reported a case in which the bone was thought to have been 
broken vertically at the junction of its anterior and middle thirds. The 
patient was a man 44 years old, and the injury was caused by jumping 
from the wheel of a carriage to the ground, alighting, it is said, on his 
heel. Swelling and ecchymosis appeared about the ankle and extended 
rapidly to the knee. There was abnormal mobility of the heel, and 
crepitus was elicited by moving the heel laterally or by contracting the 
muscles of the calf. The patient made a good recovery except for exu- 
berant callus below and in front of the malleoli which interfered some- 
what with the freedom of the ankle-joint. 

The symptoms are somewhat indefinite, and the diagnosis not always 
easy, as is shown by the fact that surgeons so experienced as Malgaigne, 
Bonnet, Huguier, and Legouest have mistaken the injury for fracture of 
the fibula or ankle. The symptoms when the bone has been crushed are 
increase of its transverse diameter, which, however, may be completely 
masked by the swelling below and about the malleoli, flatness of the sole 
and approximation to it of the malleoli, especially of the internal one, 
pain, and loss of function. Crepitation is either absent or obscure, and 
the heel is sometimes lengthened, and sometimes shortened, either actually 
or apparently in consequence of its elevation. 

When the direction of the violence with reference to the axis of the 
leg is such that the foot is adducted or inverted by it the strain is brought 
upon the external lateral ligament and the sustentaculum tali with the 
result of producing fracture of the fibula as described on page 579, or 
rupture of the external lateral ligament, or avulsion of a scale of bone 
from the side of the calcaneum where the ligament is inserted, or frac- 
ture of the sustentaculum tali. 

With the first of these we have not here to deal. A case of avulsion 
of a scale of bone came under my observation at the Presbyterian Hos- 
pital in November, 1880 ; the patient had fallen from a height of ten feet, 

1 Med. Chir. Trans., vol. xxxix., 1856. 



FRACTURE OF THE CALCANEUM. 591 

striking upon his left foot. I saw him on the following clay and found 
the foot and ankle much swollen with obscure crepitation and pain on mani- 
pulation of the side of the heel below the outer malleolus. The swelling 
subsided under lead and opium lotions, and in a few days I could dis- 
tinctly make out a movable flat fragment evidently detached from the 
outer side of the calcaneum below the malleolus. The movements of 
the foot and ankle were normal and painless except when the peroneal 
muscles were made to contract, then pain was felt below the external 
malleolus. The sheath of the tendons of these muscles was swollen 
below and behind the malleolus. 

Fracture of the sustentaculum tali was first described by Abel. 1 In 
his first case the injury was thought to be a Pott's fracture of the ankle, 
and its real character was disclosed at the autopsy. The patient was a 
young man who in dismounting from a horse slipped on a stone and 
turned his foot forcibly inward. He attempted to w T alk, and the position 
of the foot then changed instantly to marked valgus. A longitudinal 
wound three inches long below the external malleolus opened the ankle- 
joint and the joint between the astragalus and calcaneum. There was 
tenderness on pressure below the internal malleolus, and on the fibula 
above the external malleolus. These symptoms together -with the appa- 
rent broadening of the ankle and eversion of the foot led to the erroneous 
diagnosis mentioned. Erysipelas set in and the patient died on the 
fifteenth day. 

The fibula and tibia were found uninjured, the sustentaculum tali broken 
off, and the external lateral ligament divided in the line of the wound. 

Abel afterwards saw two cases in w T hich he thought this injury had 
been received some time before. In both the foot had been violently 
inverted, and in one the sustentaculum tali seemed to be doubled in size. 
The symptoms, primary and ultimate, corresponded to the following which 
he gives as diagnostic of the injury. 

1. The mode of production : forcible inversion of the sole of the foot. 

2. The immediate change in the position of the foot, from inversion to 
eversion, and the permanent sinking of the inner border of the foot and 
internal malleolus (valgus). 

3. Shortening of the heel by slight displacement of the calcaneum 
fonvard; this can be best recognized by measuring from one malleolus 
to the other around the heel, and was verified by experiment. 

4. Pain and disability. 

Fracture by muscular action, contraction of the soleus and gastro- 
cnemii, has been observed a number of times. Malgaigne collected 8 
cases, rather briefly reported ; in 2 the fracture was caused by a misstep, 
and in 5 by a fall upon the feet, in two of w T hich it is noted that the 
patient alighted upon the ball of the foot. The fracture seems to take 
place always behind the astragalus and sometimes to separate only a 
portion corresponding to the insertion of the tendo Achillis. The dis- 
placement in some cases w r as slight, in others extreme, 4J inches from 
the lower edge of the fragment to the bottom of the heel in Constance's 2 

1 Arcliiv. fiir Klin. Chirurgie, vol. xxii., 1S78, p. 396. 

2 Am. Joum. Med. Sc, 1829, p. 222, quoting from an English journal. 



592 FRACTURES OF THE BONES OF THE FOOT. 

case, in which, nevertheless, the patient made a good recovery with per- 
fect use of the limb, although the displacement persisted. 

In a recent case reported by Anningson 1 the mechanism of the fracture 
seems very clear. A woman 42 years old, after stepping clown from a 
doorway to the sidewalk, a distance of about six inches, cried out that 
she had "put out her ankle." She walked home slowly, a distance of 
one hundred yards. A fragment of bone was found 2J inches above the 
heel in the line of the tendo Achillis which was lacking below it ; its 
lower edge was a little above the level of the lower end of the internal 
malleolus ; it measured one inch transversely and " had been torn off 
the posterior surface of the os calcis where a cavity could be felt. The 
whole depth of the bone had not been torn away, but only the upper 
three-fourths, and the inferior edge of the fragment was tilted backward. 
The usual treatment of ruptured tendo Achillis was adopted," and eight 
weeks afterward the patient was able to walk without limping and com- 
plained only of some loss of spring. 

The treatment will vary somewhat with the character and position of 
the fracture. In the first variety, fracture in the anterior two-thirds 
with or without crushing, simple immobilization of the limb is all that 
can be done, except in case of need such additional measures as may 
seem' fitted to prevent or control inflammation. 

After fracture of the sustentaculum tali the foot should be immobil- 
ized in a plaster bandage or splints with the sole sufficiently inverted to 
favor reunion of the fragments, but without leno-thenino; of the external 
lateral ligaments if they have been torn. 

After fracture by muscular action with displacement upward of the 
fragment attached to the tendon the foot should be maintained in the 
position of complete plantar flexion, and it is sometimes advisable to flex 
the knee also. This can be done by a plaster dressing, or an anterior 
splint, or a shoe with a cord extending from its hoel to a band about the 
upper part of the leg or the lower part of the thigh. 

C. Fractures of the Metatarsal Bones. — These are usually the 
result of direct violence, and consequently are often associated with con- 
tusion or laceration of the skin even when the fracture is not compound. 
The first is the one most frequently broken, the fifth is next in order of 
frequency. 

There is but little tendency to displacement except when several 
bones are broken at the same time, and the usual displacement is of the 
broken end of either fragment towards the dorsum of the foot. 

The diagnosis is made by localized pain, abnormal mobility and 
crepitus when the first or fifth is broken, and pain when the correspond- 
ing toe is pressed bodily backward against the metatarsus. 

A simple fracture is not a serious injury, its course is uncomplicated, 
its result favorable, but a compound fracture may lead to much burrow- 
ing of pus, necrosis of the fragments, and grave inflammatory complica- 
tions, and the treatment should be directed actively to their prevention ; 
if buppuration becomes profuse the freest possible drainage should be 

> Brit. Med. Journal, 1878, vol. i. p. 128. 



FRACTURES OF THE PHALANGES. 593 

provided and counter-openings made on the sole or dorsum as the case 
may require. 

The limb and foot may be supported upon a moulded splint of plaster, 
felt, or pasteboard, and secured to it with a roller bandage. In com- 
pound fracture the gauze dressings will usually immobilize the fragments 
sufficiently. 

D. Fractures of the Phalanges. — These are caused by direct vio- 
lence and are usually compound, and, as in similar injuries of the hand, 
may be the starting point of very serious inflammatory complications. 
Immersion of the foot in a bath containing one or two per cent, of car- 
bolic acid once or twice daily for an hour each time is a valuable means 
of arresting commencing inflammation. 

The dressings of a compound fracture will immobilize the toe suffi- 
ciently, and in a simple fracture it is usually sufficient to place the foot 
on a splint. If it is thought desirable the toe itself may be steadied by 
strips of adhesive plaster applied longitudinally to its dorsum and sides, 
or it may be made fast to the adjoining ones. 



38 



INDEX. 



% BSORPTION of bone after fracture, 122, 
A 198 
Acetabulum, 479 

rim, 486 
Age, influence of, on fracture, 36 
on prognosis, 226 
on repair, 200 
Amputation, 194 
Aneurism, traumatic, 137 

after fracture of rib, 309 
Ankle, Pott's fracture, 581 
Antiseptic dressings, 18^ 
Arrest of growth, 51, 129 
Arteries, injuries of, 137. (See also under 

complications of special fractures.) 
Astragalus, 588 

Asymmetry, normal, of limbs, 101 
Atlas, 263 

Atrophy of bone, 198 
of limb, 131 
senile, 78 
Axis, 263 



BARTON'S fracture of the radius, 453 
Bavarian splint, 173 
Bivalve cushion, 161 
Boxes, fracture, 163 
Bridge, periosteal, 117 
Buck's extension, 181 



CALCANEUM, 589 
Callus, absorption of, 204, 207 
exuberant, 126, 146 
formation of, 118 
painful, 146 

retarding influences upon, 201 
Cancer, a cause of fracture, 86 
Caries, a cause of fracture, 89 
Carpus, 466 

Cartilage, in false joints, 199 
Cartilages, fracture of costal, 319 
Causes of fracture, 76 

determining, 90 

muscular action, 92 
predisposing, 76 

acquired tendency, 80 
cancer, 86 

caries and necrosis, 89 
congenital tendency, 79 



Causes of fracture, predisposing — 
inherited tendency, 79 
nervous disease, 82 
rachitis, 83 
syphilis, 84 
Clavicle, 323 

complications, 330, 336 
etiology, 332 
pathology, 324 

simultaneous fracture of both, 333 
symptoms and course, 334 
treatment, 337 
Coccyx, 482 

Comminuted fractures, 57 
Complete fractures, 43 
Complications of fracture, 130 
Compound fractures, 59 
prognosis, 227 
treatment, 185 
Condyloid process of inferior maxilla, 285 
Consequences, remote, 130 
Coronoid process of inferior maxilla, 286 

of ulna, 427 
Cowling, aphorisms, 195 
Crepitation, 105 
Crushing, fracture with, 57 



DEFORMITY, a symptom, 100 
Delirium, 145 
Depressions, 42 
Diagnosis, 101 
Displacements, 67 
Drilling in pseudarthrosis, 212 



EMBOLISM, 132 
fat, 133 
Emphysema, 138 
Epiphysis, separation of, 49 
Epitrochlea, 391 
Etiology, 76 

Extension, continuous, 179 
Extravasation, 136 



FAILURE of union, 122 
Femur, 488 

fractures at the lower end, 538 
intercondyloid, 540 
of either condyle, 543 



596 



INDEX. 



Femur, fractures at the lower end — 

separation of the epiphysis, 

539 
supracondyloid, 538 
at the upper end, 488 

of the great trochanter, 522 
of the neck, 489 
causes, 491 
diagnosis, 513 
prognosis, 515 
symptoms, 508 
treatment, 517 
varieties, 492 

base of neck (extra- 
capsular), 504 
narrow part (intra- 
capsular), 494 
through the great trochanter 
and neck, 520 
of the shaft, 524 
prognosis, 528 
treatment, 529 

in children, 536 
Fenestrated splints, 175 
Fibula, 586 
Fingers, 469 
Fissures, 38 
Foot, 588 
Forearm, 418 

at the upper end, 418 
at the wrist, 446 
of the shaft, 435 
Fox's dressing for fractured clavicle, 342 



GANGRENE, 140 
Green-stick fractures, 39 
Growth, arrest of, 51 
Gue'rin's dressing for compound fractures, 

191 
Gunshot fractures, 62, 194 

prognosis, 227 
Gutters, wire, 164 



HEART, wounded in fracture of rib, 311 
Hemorrhage, 137 
in fracture of skull, 241 
Hodgen's splint, 167 
Humerus, 356 

lower end, 389 

above the condyles, 390 
articular process, 413 
diagnosis, 414 
epitrochlea, 391 
external condyle, 403 
external epicondyle, 395 
intercondyloid fracture, 405 
internal condyle, 396 
separation of epiphysis, 411 
simultaneous fracture of the three 

bones, 414 
treatment, 415 
shaft, 384 
upper end, 357 



Humerus, upper end — 
diagnosis, 377 
pathology and course, 357 

anatomical neck and tuber- 
osities, 358 
head, 357 

separation of epiphysis, 365 
surgical neck, 369 

with dislocation, 
372 
tuberosities, 362 
treatment, 379 
Hyoid bone, 295 



TL1UM, 483 

JL Immobilization of joints, 184 
Incomplete fractures, 38 
Inherited tendency to fracture, 79 
Interrupted splints, 175 
Intra-articular fracture, 52 

repair of, 125 
Ischium, 484 
Iterative fracture, 152 



LARYNX, 297 
Leg, fractures of, 564 
fibula, 586 
lower third, 576 

by eversion, 581 
by inversion, 578 
shaft, 566 

injury to vessels, 569 
upper end, 564 
Lister dressing, 188 

treatment of compound articular frac- 
tures, 194 
Longitudinal fractures, 46 
Luug, hernia of, 314, 320 

injured in fracture of ribs, 309 
in fracture of clavicle, 331 



MALAR bone, 280 
Malgaigne's hooks, 169, 560 
point, 168, 575 
Markoe's "through drainage," 190 
M axilla, inferior, 284 

condyloid process, 285 
coronoid process, 286 
treatment, 289 
superior, 282 
Mayor's scarf or sling, 340 
Metacarpal bones, 467 
Metatarsal bones, 592 
Mobility, abnormal, 104 
Moore on fracture of clavicle, 343 

on separation of epiphysis of humerus, 
366 
Moulded splints, 169 
Multiple fractures, 55 
Muscular action, a cause of fracture, 92 
spasms an obstacle to reduction, 155 
twitchings, 144 



INDEX. 



597 



YTECROSIS, 123, 143 

_L\ Nerve disease, a cause of fracture, 
82 

inclusion in callus, 150 

injury in fractures of clavicle, 331 
Nose, 277 
Nutrient artery, influence on repair, 203 



OBLIQUE fractures, 45 
Olecranon, 418 
Oilier, treatment of compound articular 
fractures, 193 



PAPINI'S brace for clavicle, 342 
Paralysis, a result of fracture, 149 

its effect on repair, 202 
Patella, 546 

course and terminations, 550 

iterative fracture, 553 

multiple fracture, 553 

pathology, 547 

simultaneous, of both, 547 

symptoms, 550 

treatment, 556 

compound, 561 
ununited, 562 
Pelvis, 472 

course, 480 

diagnosis, 480 

double vertical fracture, 478 

lateral portion of ring, 477 

pubic portion of ring, 476 

separation in front and behind, 475 
of all three joints, 475 
of pubic symphysis. 473 
of sacro-iliac symphysis, 475 
Periosteal bridge, 117 
Periosteum, extent of injury, 117 

share in repair, 118 
Plane, double inclined, 179 
Plaster of Paris, 170 
Pott's fracture at ankle, 581 
Prognosis, general, 226 
Pseudarthrosis, 122, 197 

causes, 201 

diagnosis, 208 

treatment, 209 
Pubis, 485 



RACHITIS, a cause, 83 
Radius, Colles's fracture, 446 

fractures at wrist other than Colles's, 
453, 464 
of head and neck, 431 
of shaft, 444 
Recamier's dressing for clavicle, 342 
Reduction, 154 
Repair, 110 

opposing influences, 201 
Resection in pseudarthrosis, 214 
Retention, 159 
Rheumatism, a cause, 85 



Ribs, 307 

etiology, 31 1 

pathology and complications, 307 

symptoms, 312 

treatment, 316 

twelfth, fracture of, 312 



SACRUM, transverse fracture, 481 
vertical fracture, 478 
Sayre's dressing for clavicle, 341 
Scapula, 345 

acromion, 350 

body, 346 

coracoid process, 351 

glenoid cavity, 354 

inferior angle, 348 

spine, 349 

surgical neck, 353 

upper angle, 349 
Scultetus bandage, 160 
Scurvy, influence on repair, 207 

local, 205 
Secondary fracture, 152 
Separation of epiphysis, 49 

of splinter, 42 
Serous discharge after fracture of skull, 

240, 243 
Seton in pseudarthrosis, 211 
Silicate of soda, 177 
Skull, 230 

pathology, base, 234 
vault, 232 

prognosis, 246 

symptoms, base, 2 J 1 
vault, 239 

treatment, base, 252 
vault, 247 
Smith's anterior splint, 166 
Spine, 253. (See Vertebrae.) 
Splinters, vitality of, 121 
Statistics, general, 34 

of failure of union, 199, 212 
Sternum, 299 

diagnosis, 303 

etiology, 302 

treatment, 305 
Stiffness of joints, 130 
Suppuration after fracture, 142, 147 
Supra-malleolar fracture, 580 
Suspended splints, 164 
Suture of bones, 187 

of clavicle, 339 
Symptoms, 101 
Syphilis, a cause, 84 



TEMPERATURE during repair, 110 
Tendency to fracture, 79 
Tetanus, 144 
Tibia, 564. (See Leg.) 
Toes, 593 

Toothed fractures, 44 
Trachea, 297 
Transverse fractures, 43 



598 



INDEX, 



Treatment, 153 

by amputation, 194 

of compound fractures, 185 

of compound articular fractures, 193 

of gunshot fractures, 194 

of pseudarthrosis, 209 

of vicious union, 219 

Tripolith, 177 



ULNA, coronoid process, 427 
olecranon, 418 
shaft, 442 
Union, deformed or faulty, 217 
delayed, or failure of, 197 
causes, 201 
diagnosis, 208 
treatment, 209 
fibrous, 128, 198 



Y-SHAPED fractures, 45 
Varieties, 37 

of direction, 43 
of seat, 48 
Veins, obliteration of, 132 



Velpeau's dressing for clavicle, 340 
Vertebrae, 253 

course and terminations, 270 
etiology, 260 
pathology, 255 
arches, 257 
bodies, 255 
processes, 258 
symptoms, 261 

atlas and axis, 263 

lower cervical and upper dorsal, 

264 
lower dorsal and upper lumbar, 

267 
lower lumbar, 269 
treatment, 274 
Volkmann's foot-rest, 182 



w 



ATERY discharge after fracture of 
skull, 243 



ZSIGMONDI'S splint, 174 
Zygoma, 280 



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